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Seelye S, Cano J, Hogan CK, Prescott HC, Sussman JB. Social Determinants of Health and Risk-Adjusted Sepsis Mortality in the Nationwide Veterans Affairs Healthcare System. J Gen Intern Med 2024; 39:3129-3137. [PMID: 39375318 PMCID: PMC11618254 DOI: 10.1007/s11606-024-09104-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 09/27/2024] [Indexed: 10/09/2024]
Abstract
IMPORTANCE Traditional risk prediction and risk adjustment models have focused on clinical characteristics, but accounting for social determinants of health (SDOH) and complex health conditions could improve understanding of sepsis outcomes and our ability to predict outcomes, treat patients, and assess quality of care. OBJECTIVE To evaluate the impact of SDOH and health scales in sepsis mortality risk prediction and hospital performance assessment. DESIGN Observational cohort study. SETTING One hundred twenty-nine hospitals in the nationwide Veterans Affairs (VA) Healthcare System between 2017 and 2021. PARTICIPANTS Veterans admitted through emergency departments with community-acquired sepsis. EXPOSURES Individual- and community-level SDOH (race, housing instability, marital status, Area Deprivation Index [ADI], and rural residence) and two health scales (the Care Assessment Need [CAN] score and Claims-Based Frailty Index [CFI]). MAIN OUTCOMES AND MEASURES The primary outcome was 90-day mortality from emergency department arrival; secondary outcomes included 30-day mortality and in-hospital mortality. RESULTS Among 144,889 patients admitted to the hospital with community-acquired sepsis, 139,080 were men (96.0%), median (IQR) age was 71 (64-77) years, and median (IQR) ADI was 60 (38-81). Multivariable regression models had good calibration and discrimination across models that adjusted for different sets of variables (e.g., AUROC, 0.782; Brier score, 1.33; and standardized mortality rate, 1.00). Risk-adjusted hospital performance was similar across all models. Among 129 VA hospitals, three hospitals shifted from the lowest or highest quintile of performance when comparing models that excluded SDOH to models that adjusted for all variables. Models that adjusted for ADI reported odds ratios (CI) of 1.00 (1.00-1.00), indicating that ADI does not significantly predict sepsis mortality in this cohort of patients. CONCLUSION AND RELEVANCE In patients with community-acquired sepsis, adjusting for community SDOH variables such as ADI did not improve 90-day sepsis mortality predictions in mortality models and did not substantively alter hospital performance within the VA Healthcare System. Understanding the role of SDOH in risk prediction and risk adjustment models is vital because it could prevent hospitals from being negatively evaluated for treating less advantaged patients. However, we found that in VA hospitals, the potential impact of SDOH on 90-day sepsis mortality was minimal.
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Affiliation(s)
- Sarah Seelye
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - Jennifer Cano
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Cainnear K Hogan
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Hallie C Prescott
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeremy B Sussman
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Mohamoud A, Abdallah N, Wardhere A, Teeri S, Ismayl M. Sepsis and septic shock outcomes and 90-day readmissions in heart failure with reduced ejection fraction: A national readmission database study. Curr Probl Cardiol 2024; 49:102696. [PMID: 38852912 DOI: 10.1016/j.cpcardiol.2024.102696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Patients with heart failure with reduced ejection fraction (HFrEF) are at increased risk for sepsis/septic shock. METHOD A retrospective study was conducted using the Nationwide Readmission Database (2016-2020). Adult patients admitted with sepsis or septic shock were identified and stratified based on the presence of underlying HFrEF. Multivariable logistic regression assessed the association between HFrEF and in-hospital mortality, 90-day readmission, and other complications. RESULTS Among 7,326,930 sepsis/septic shock admissions, 6.2 % had HFrEF. HFrEF patients had higher in-hospital mortality (17 % vs. 9.6 %, p < 0.01) and 90-day readmission rates (30.2 % vs. 22.5 %, p < 0.01) compared to those without HFrEF. These differences persisted after adjustment with increased risk of in-hospital mortality (aOR 1.40, 95 %CI 1.38-1.42) and 90-day readmission (aOR 1.15, 95 %CI 1.13-1.16). CONCLUSION HFrEF patients admitted with sepsis/septic shock have significantly higher rates of in-hospital mortality, complications, and 90-day readmissions compared to those without HFrEF.
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Affiliation(s)
- Abdilahi Mohamoud
- Department of Internal Medicine, Hennepin Healthcare, Minneapolis, MN, USA.
| | - Nadhem Abdallah
- Department of Internal Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | | | - Samira Teeri
- Department of Internal Medicine, MedStar Washington Hospital Center, Georgetown University, Washington DC, USA
| | - Mahmoud Ismayl
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Wang X, Li S, Cao Q, Chang J, Pan J, Wang Q, Wang N. Development and validation of a nomogram model for predicting 28-day mortality in patients with sepsis. Heliyon 2024; 10:e35641. [PMID: 39220984 PMCID: PMC11365313 DOI: 10.1016/j.heliyon.2024.e35641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 07/31/2024] [Accepted: 08/01/2024] [Indexed: 09/04/2024] Open
Abstract
Background This study aimed to develop and validate a nomogram model for predicting 28-day mortality in patients with sepsis in the intensive care unit (ICU). Methods We retrospectively analyzed data from 331 patients with sepsis admitted to the ICU as a training set and collected a validation set of 120 patients. Both groups were followed for 28 days. Logistic regression analyses were performed to identify the potential prognostic factors for sepsis-related 28-day mortality. A nomogram model was generated to predict 28-day mortality in patients with sepsis in the ICU. Receiver operating characteristic (ROC) curve analysis, calibration curves, and decision curve analysis (DCA) were used to evaluate the model's prediction performance and clinical application. In addition, we used ROC curve analysis and DCA to compare this model with the sequential organ failure assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores and further assessed the clinical value of our model. Results Logistic multivariate regression analysis revealed that mechanical ventilation, oxygenation index, and lactate and blood urea nitrogen (BUN) levels were independent predictors of 28-day mortality in patients with sepsis in the ICU. We developed a nomogram model based on these results to further predict 28-day mortality. The model demonstrated satisfactory calibration curves for both training and validation sets. Additionally, in the training set, the area under the ROC curve (AUC) for this model was 0.80. In the validation set, the AUC was 0.82. DCA showed that the high-risk thresholds ranged between 0 and 0.86 in the training set and between 0 and 0.75 in the validation set. We compared the ROC curve and DCA of this model with those of SOFA and APACHE II scores in both the training and validation sets. In the training set, the AUC of this model was significantly higher than those of the SOFA (P = 0.032) and APACHE II (P = 0.004) scores. Although the validation set showed a similar trend, the differences were not statistically significant for the SOFA (P = 0.273) and APACHE II (P = 0.320) scores. Additionally, the DCA showed comparable clinical utility in all three assessments. Conclusion The present study used four common clinical variables, including mechanical ventilation, oxygenation index and lactate and BUN levels, to develop a nomogram model to predict 28-day mortality in patients with sepsis in the ICU. Our model demonstrated robust prediction performance and clinical application after validation and comparison.
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Affiliation(s)
- Xiaoqian Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Public Health Clinical Center, Hefei, Anhui, China
| | - Shuai Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Quanxia Cao
- Anhui Sanlian University, Hefei, Anhui, China
| | - Jingjing Chang
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Public Health Clinical Center, Hefei, Anhui, China
| | - Jingjing Pan
- Department of Pulmonary and Critical Care Medicine, Anhui Chest Hospital, Hefei, Anhui, China
| | - Qingtong Wang
- Institute of Clinical Pharmacology, Anhui Medical University, Hefei, Anhui, China
| | - Nan Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Public Health Clinical Center, Hefei, Anhui, China
- Anhui Provincial Institute of Translational Medicine, Anhui Medical University, 81 Meishan Road, Hefei, Anhui, China
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Zhu MY, Tang XK, Gao Y, Xu JJ, Gong YQ. Impact of heart failure on outcomes in patients with sepsis: A systematic review and meta-analysis. World J Clin Cases 2023; 11:3511-3521. [PMID: 37383893 PMCID: PMC10294198 DOI: 10.12998/wjcc.v11.i15.3511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/06/2023] [Accepted: 04/06/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND Heart failure (HF) often affects the progress of sepsis patients, although its impact on outcomes is inconsistent and inconclusive.
AIM To conduct a systematic review and meta-analysis of the impact of HF on mortality in patients with sepsis.
METHODS PubMed, Embase, Web of Science, and the Cochrane Library databases were searched to compare the outcomes of sepsis patients with HF. A random effect model was used to summarize the mortality data, and the odds ratio (OR) and 95% confidence interval (CI) were calculated as effect indicators.
RESULTS Among 18001 records retrieved in the literature search, 35712 patients from 10 separate studies were included. The results showed that sepsis patients with HF were associated with increased total mortality (OR = 1.80, 95%CI: 1.34-2.43; I2 = 92.1%), with high heterogeneity between studies. Significant subgroup differences according to age, geographical location, and HF patient sample were observed. HF did not increase the 1-year mortality of patients (OR = 1.11, 95%CI: 0.75-1.62; I2 = 93.2%), and the mortality of patients with isolated right ventricular dysfunction (OR=2.32, 95%CI: 1.29-4.14; I2 = 91.5%) increased significantly.
CONCLUSION In patients with sepsis, HF is often associated with adverse outcomes and mortality. Our results call for more high-quality research and strategies to improve outcomes for sepsis patients with HF.
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Affiliation(s)
- Ming-Yu Zhu
- Department of the Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Xiao-Kai Tang
- Department of the Orthopaedic, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Yi Gao
- Department of the Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Jing-Jing Xu
- Department of the Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Yuan-Qi Gong
- Department of the Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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Park H, Lee J, Oh DK, Park MH, Lim CM, Lee SM, Lee HY. Serial evaluation of the serum lactate level with the SOFA score to predict mortality in patients with sepsis. Sci Rep 2023; 13:6351. [PMID: 37072424 PMCID: PMC10113181 DOI: 10.1038/s41598-023-33227-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 04/10/2023] [Indexed: 05/03/2023] Open
Abstract
In patients with sepsis, outcome prediction plays an important role in influencing therapeutic decision making. In this nationwide, prospective, observational cohort study of sepsis patients conducted between September 2019 and December 2020, we evaluated a novel scoring system using serial Sequential Organ Failure Assessment (SOFA) scores and serum lactate to accurately predict mortality in sepsis. Based on the serum lactate score (Lac-score), patients were assigned to 5 categories: lactate < 2, ≥ 2 to < 4, ≥ 4 to < 8, ≥ 8 to < 12, and ≥ 12 mmol/L. Lac-SOFA score was defined as the sum of Lac-score and SOFA score. After screening 7113 patients, 379 were excluded and 6734 were included in analysis. In-hospital mortality AUROC for serial Lac-SOFA score from initial to ICU day 3 was significantly higher than that for serial SOFA score (initial, 0.679 vs. 0.656, day 1, 0.723 vs. 0.709, day 2, 0.760 vs. 0.747, and day 3, 0.797 vs. 0.781; DeLong's test, p < 0.001). The initial Lac-SOFA score significantly correlated with in-hospital mortality when the patients were divided into five classes based on 5-point intervals (p < 0.05). Serial evaluation of lactate levels with the SOFA score may improve the predictive accuracy of the SOFA score for determining mortality risk in sepsis patients.
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Affiliation(s)
- Heemoon Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dong Kyu Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi Hyeon Park
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Critical Care Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hong Yeul Lee
- Department of Critical Care Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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Murlidharan A. Predictive Value of Frailty Index in Comparison to Traditional Markers of Sepsis in Predicting Mortality among Elderly Admitted in Tertiary Care Hospital. JOURNAL OF THE ASSOCIATION OF PHYSICIANS OF INDIA 2022; 70:11-12. [DOI: 10.5005/japi-11001-0094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Hilton RS, Hauschildt K, Shah M, Kowalkowski M, Taylor S. The Assessment of Social Determinants of Health in Postsepsis Mortality and Readmission: A Scoping Review. Crit Care Explor 2022; 4:e0722. [PMID: 35928537 PMCID: PMC9345631 DOI: 10.1097/cce.0000000000000722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To summarize knowledge and identify gaps in evidence about the relationship between social determinants of health (SDH) and postsepsis outcomes. DATA SOURCES We conducted a comprehensive search of PubMed/Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, and the Cochrane Library. STUDY SELECTION We identified articles that evaluated SDH as risk factors for mortality or readmission after sepsis hospitalization. Two authors independently screened and selected articles for inclusion. DATA EXTRACTION We dual-extracted study characteristics with specific focus on measurement, reporting, and interpretation of SDH variables. DATA SYNTHESIS Of 2,077 articles screened, 103 articles assessed risk factors for postsepsis mortality or readmission. Of these, 28 (27%) included at least one SDH variable. Inclusion of SDH in studies assessing postsepsis adverse outcomes increased over time. The most common SDH evaluated was race/ethnicity (n = 21, 75%), followed by payer type (n = 10, 36%), and income/wealth (n = 9, 32%). Of the studies including race/ethnicity, nine (32%) evaluated no other SDH. Only one study including race/ethnicity discussed the use of this variable as a surrogate for social disadvantage, and none specifically discussed structural racism. None of the studies specifically addressed methods to validate the accuracy of SDH or handling of missing data. Eight (29%) studies included a general statement that missing data were infrequent. Several studies reported independent associations between SDH and outcomes after sepsis discharge; however, these findings were mixed across studies. CONCLUSIONS Our review suggests that SDH data are underutilized and of uncertain quality in studies evaluating postsepsis adverse events. Transparent and explicit ontogenesis and data models for SDH data are urgently needed to support research and clinical applications with specific attention to advancing our understanding of the role racism and racial health inequities in postsepsis outcomes.
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Affiliation(s)
- Ryan S Hilton
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - Katrina Hauschildt
- Center for Clinical Management and Research, VA Ann Arbor Health Care System, Ann Arbor, MI
| | - Milan Shah
- Department of Internal Medicine, Carolinas Medical Center, Charlotte, NC
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC
| | - Stephanie Taylor
- Department of Internal Medicine, Wake Forest University School of Medicine Atrium Health Enterprise, Charlotte, NC
- Critical Illness, Injury, and Recovery Research Center, Wake Forest School of Medicine, Winston-Salem, NC
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Thietart S, Boumendil A, Pateron D, Guidet B, Vallet H. Impact on 6-month outcomes of hospital trajectory in critically ill older patients: analysis of the ICE-CUB2 clinical trial. Ann Intensive Care 2022; 12:65. [PMID: 35819563 PMCID: PMC9274629 DOI: 10.1186/s13613-022-01042-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/27/2022] [Indexed: 11/21/2022] Open
Abstract
Background Little is known about the impact of hospital trajectory on survival and functional decline of older critically ill patients. We evaluate 6-month outcomes after admission to: intensive care units (ICU), intermediate care units (IMCU) or acute medical wards (AMW). Methods Data from the randomised prospective multicentre clinical trial ICE-CUB2 was secondarily analysed. Inclusion criteria were: presenting at emergency departments in critical condition; age ≥ 75 years; activity of daily living (ADL) ≥ 4; preserved nutritional status; and no active cancer. A Cox model was fitted to compare survival according to admission destination adjusting for patient characteristics. Sensitivity analysis using multiple imputation for missing data and propensity score matching were performed. Results Among 3036 patients, 1675 (55%) were women; median age was 85 [81–99] years; simplified acute physiology score (SAPS-3) 62 [55–69]; 1448 (47%) were hospitalised in an ICU, 504 in IMCU (17%), and 1084 (36%) in AMW. Six-month mortality was 629 (44%), 155 (31%) and 489 (45%) after admission in an ICU, IMCU and AMW (p < 0.001), respectively. In multivariate analysis, AMW admission was associated with worse 6-month survival (HR 1.31, 95% CI 1.04–1.63) in comparison with IMCU admission, after adjusting for age, gender, comorbidities, ADL, SAPS-3 and diagnosis. Survival was not significantly different between patients admitted in an ICU and an IMCU (HR 1.17, 95% CI 0.95–1.46). Sensitivity analysis using multiple imputation for missing data and propensity score matching found similar results. Hospital destination was not significantly associated with the composite criterion loss of 1-point ADL or mortality. Physical and mental components of the 12-Item Short-Form Health Survey were significantly lower in the acute medical ward group (34.3 [27.5–41.7], p = 0.037 and 44.3 [38.6–48.6], p = 0.028, respectively) than in the ICU group (34.7 [28.4–45.3] and 45.5 [40.0–50.0], respectively) and IMCU group (35.7 [29.7–43.8] and 44.5 [39.7–48.4], respectively). Conclusions Admission in an AMW was associated with worse 6-month survival in older critically ill patients in comparison with IMCU admission, with no difference of survival between ICU and IMCU admission. There were no clinically relevant differences in quality of life in each group. These results should be confirmed in specific studies and raise the question of dedicated geriatric IMCUs. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01042-4.
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Affiliation(s)
- Sara Thietart
- Department of Intensive Care, APHP, Hôpital Saint-Antoine, Sorbonne Université, 184, rue du Faubourg Saint-Antoine, 75012, Paris, France.
| | | | - Dominique Pateron
- Department of Emergency, APHP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Bertrand Guidet
- Department of Intensive Care, APHP, Hôpital Saint-Antoine, Sorbonne Université, 184, rue du Faubourg Saint-Antoine, 75012, Paris, France.,INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, APHP, Hôpital Saint-Antoine, Paris, France
| | - Hélène Vallet
- Department of Geriatrics, APHP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France.,INSERM U1135, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
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Spoden M, Hartog CS, Schlattmann P, Freytag A, Ostermann M, Wedekind L, Storch J, Reinhart K, Günster C, Fleischmann-Struzek C. Occurrence and Risk Factors for New Dependency on Chronic Care, Respiratory Support, Dialysis and Mortality in the First Year After Sepsis. Front Med (Lausanne) 2022; 9:878337. [PMID: 35665356 PMCID: PMC9162443 DOI: 10.3389/fmed.2022.878337] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/27/2022] [Indexed: 12/14/2022] Open
Abstract
Sepsis survival is associated with adverse outcomes. Knowledge about risk factors for adverse outcomes is lacking. We performed a population-based cohort study of 116,507 survivors of hospital-treated sepsis identified in health claims data of a German health insurance provider. We determined the development and risk factors for long-term adverse events: new dependency on chronic care, chronic dialysis, long-term respiratory support, and 12-month mortality. At-risk patients were defined by absence of these conditions prior to sepsis. Risk factors were identified using simple and multivariable logistic regression analyses. In the first year post-sepsis, 48.9% (56,957) of survivors had one or more adverse outcome, including new dependency on chronic care (31.9%), dialysis (2.8%) or respiratory support (1.6%), and death (30.7%). While pre-existing comorbidities adversely affected all studied outcomes (>4 comorbidities: OR 3.2 for chronic care, OR 4.9 for dialysis, OR 2.7 for respiratory support, OR 4.7 for 12-month mortality), increased age increased the odds for chronic care dependency and 12-month mortality, but not for dialysis or respiratory support. Hospital-acquired and multi-resistant infections were associated with increased risk of chronic care dependency, dialysis, and 12-month mortality. Multi-resistant infections also increased the odds of respiratory support. Urinary or respiratory infections or organ dysfunction increased the odds of new dialysis or respiratory support, respectively. Central nervous system infection and organ dysfunction had the highest OR for chronic care dependency among all infections and organ dysfunctions. Our results imply that patient- and infection-related factors have a differential impact on adverse life changing outcomes after sepsis. There is an urgent need for targeted interventions to reduce the risk.
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Affiliation(s)
- Melissa Spoden
- Research Institute of the Local Health Care Funds (AOK), Berlin, Germany
| | - Christiane S. Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
- Klinik Bavaria, Kreischa, Germany
| | - Peter Schlattmann
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Antje Freytag
- Institute of General Practice and Family Medicine, Jena University Hospital, Jena, Germany
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Lisa Wedekind
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Josephine Storch
- Institute of General Practice and Family Medicine, Jena University Hospital, Jena, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Günster
- Research Institute of the Local Health Care Funds (AOK), Berlin, Germany
| | - Carolin Fleischmann-Struzek
- Center for Sepsis Control and Care, Jena University Hospital/Friedrich Schiller University Jena, Jena, Germany
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
- *Correspondence: Carolin Fleischmann-Struzek
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Chen SH, Wang YC, Chao A, Liu CM, Chiu CT, Wang MJ, Yeh YC. Early prediction of survival at different time intervals in sepsis patients: A visualized prediction model with nomogram and observation study. Tzu Chi Med J 2022; 34:55-61. [PMID: 35233357 PMCID: PMC8830554 DOI: 10.4103/tcmj.tcmj_3_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/22/2021] [Accepted: 03/12/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Sepsis is a major cause of death around the world. Complicated scoring systems require time to have data to predict short-term survival. Intensivists need a tool to predict survival in sepsis patients easily and quickly. MATERIALS AND METHODS This retrospective study reviewed the medical records of adult patients admitted to the surgical intensive care units between January 2009 and December 2011 in National Taiwan University Hospital. For this study, 739 patients were enrolled. We recorded the demographic and clinical variables of patients diagnosed with sepsis. A Cox proportional hazard model was used to analyze the survival data and determine significant risk factors to develop a prediction model. This model was used to create a nomogram for predicting the survival rate of sepsis patients up to 3 months. RESULTS The observed 28-day, 60-day, and 90-day survival rates were 71.43%, 52.53%, and 46.88%, respectively. The principal risk factors for survival prediction included age; history of dementia; Glasgow Coma Scale score; and lactate, creatinine, and platelet levels. Our model showed more favorable prediction than did Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment at sepsis onset (concordance index: 0.65 vs. 0.54 and 0.59). This model was used to create the nomogram for predicting the mortality at the onset of sepsis. CONCLUSION We suggest that developing a nomogram with several principal risk factors can provide a quick and easy tool to early predict the survival rate at different intervals in sepsis patients.
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Affiliation(s)
- Shih-Hong Chen
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
- Institute of Molecular Medicine, National Tsing Hua University, Hsinchu, Taiwan
| | - Yi-Chia Wang
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Anne Chao
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Min Liu
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Tang Chiu
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Jiuh Wang
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Chang Yeh
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
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Wang C, Liang G, Shen J, Kong H, Wu D, Huang J, Li X. Long Non-Coding RNAs as Biomarkers and Therapeutic Targets in Sepsis. Front Immunol 2021; 12:722004. [PMID: 34630395 PMCID: PMC8492911 DOI: 10.3389/fimmu.2021.722004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/18/2021] [Indexed: 12/14/2022] Open
Abstract
Sepsis, an infection-induced systemic inflammatory disorder, is often accompanied by multiple organ dysfunction syndromes with high incidence and mortality rates, and those who survive are often left with long-term sequelae, bringing great burden to social economy. Therefore, novel approaches to solve this puzzle are urgently needed. Previous studies revealed that long non-coding RNAs (lncRNAs) have exerted significant influences on the process of sepsis. The aim of this review is to summarize our understanding of lncRNAs as potential sepsis-related diagnostic markers and therapeutic targets, and provide new insights into the diagnosis and treatment for sepsis. In this study, we also introduced the current diagnostic markers of sepsis and discussed their limitations, while review the research advances in lncRNAs as promising biomarkers for diagnosis and prognosis of sepsis. Furthermore, the roles of lncRNAs in sepsis-induced organ dysfunction were illustrated in terms of different organ systems. Nevertheless, further studies should be carried out to elucidate underlying molecular mechanisms and pathological process of sepsis.
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Affiliation(s)
- Chuqiao Wang
- The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, State Key Laboratory of Respiratory Disease, Sino-French Hoffmann Institute, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, China.,Nanshan School, Guangzhou Medical University, Guangzhou, China
| | - Guorui Liang
- Nanshan School, Guangzhou Medical University, Guangzhou, China
| | - Jieni Shen
- Nanshan School, Guangzhou Medical University, Guangzhou, China
| | - Haifan Kong
- Nanshan School, Guangzhou Medical University, Guangzhou, China
| | - Donghong Wu
- Nanshan School, Guangzhou Medical University, Guangzhou, China
| | - Jinxiang Huang
- The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, State Key Laboratory of Respiratory Disease, Sino-French Hoffmann Institute, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, China
| | - Xuefeng Li
- The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, State Key Laboratory of Respiratory Disease, Sino-French Hoffmann Institute, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, China.,Shenzhen Luohu People's Hospital, The Third Affiliated Hospital of Shenzhen University, Shenzhen, China
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12
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Haug VF, Tapking C, Panayi AC, Thiele P, Wang AT, Obed D, Hirche C, Most P, Kneser U, Hundeshagen G. Long-term sequelae of critical illness in sepsis, trauma and burns: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 91:736-747. [PMID: 34252062 DOI: 10.1097/ta.0000000000003349] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sepsis, major trauma, and severe burn injury are life-threatening critical illnesses that remain significant contributors to worldwide morbidity and mortality. The three underlying etiologies share pathophysiological similarities: hyperinflammation, hypermetabolism, and acute immunomodulation. The aims of this study were to assess the current state of long-term outcome research and to identify key outcome parameters between the three forms of critical illness. METHODS This systematic review and meta-analysis (MA) were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed was searched from January 1, 1975, to December 31, 2019. Studies were assessed for eligibility by independent reviewers. Inclusion criteria were studies reporting at least a 6-month follow-up of health-related quality of life and organ-specific sequelae within the three etiologies: severe burn injury, sepsis, and major trauma. RESULTS In total, 125 articles could be included in the systematic review and 74 in the MA. The mean follow-up time was significantly longer in burn studies, compared with sepsis and trauma studies. The majority of patients were from the sepsis group, followed by burns, and major trauma studies. In the overall health-related quality of life, as assessed by Short Form 36 and European Quality-of-Life Index, the three different etiologies were comparable with one another. CONCLUSION The effects of critical illness on survivors persist for years after hospitalization. Well-reported and reliable data on the long-term outcomes are imperative, as they can be used to determine the treatment choice of physicians and to guide the expectations of patients, improving the overall quality of care of three significant patient cohorts. LEVEL OF EVIDENCE Systematic review and MA, level III.
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Affiliation(s)
- Valentin F Haug
- From the Department of Hand, Plastic and Reconstructive Surgery (V.F.H., C.T., P.T., C.H., U.K., G.H.), Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Plastic, Hand and Reconstructive Microsurgery (C.H.), Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, Affiliated Hospital to the Goethe-University Frankfurt am Main, Germany; German Center for Cardiovascular Research (DZHK) (P.M.), Partner site Heidelberg/Mannheim, Heidelberg; Division of Plastic Surgery, Department of Surgery (V.F.H., A.C.P., A.T.W., D.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Molecular and Translational Cardiology (P.T.), and Department of Internal Medicine III (P.M.), University Hospital, Heidelberg, Germany; and Division of Molecular and Translational Cardiology, Department of Internal Medicine III (P.M.), University Hospital, Heidelberg, Germany
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13
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Acharya R, Patel A, Schultz E, Bourgeois M, Kandinata N, Paswan R, Kafle S, Sedhai YR, Younus U. Fluid resuscitation and outcomes in heart failure patients with severe sepsis or septic shock: A retrospective case-control study. PLoS One 2021; 16:e0256368. [PMID: 34411178 PMCID: PMC8376054 DOI: 10.1371/journal.pone.0256368] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/04/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The use of ≥30 mL/Kg fluid bolus in congestive heart failure (CHF) patients presenting with severe sepsis or septic shock remained controversial due to the paucity of data. METHODS The retrospective case-control study included 671 adult patients who presented to the emergency department of a tertiary care hospital from January 01, 2017 to December 31, 2019 with severe sepsis or septic shock. Patients were categorized into the CHF group and the non-CHF group. The primary outcome was to evaluate the compliance with ≥30 mL/Kg fluid bolus within 6 hours of presentation. The comparison of baseline characteristics and secondary outcomes were done between the groups who received ≥30 mL/Kg fluid bolus. For the subgroup analysis of the CHF group, it was divided based on if they received ≥30 mL/Kg fluid bolus or not, and comparison was done for baseline characteristics and secondary outcomes. Univariate and multivariable analyses were performed to explore the differences between the groups for in-hospital mortality and mechanical ventilation. RESULTS The use of ≥30 mL/Kg fluid bolus was low in both the CHF and non-CHF groups [39% vs. 66% (p<0.05)]. Mortality was higher in the CHF group [33% vs 18% (p<0.05)]. Multivariable analysis revealed that the use of ≥30 mL/Kg fluid bolus decreased the chances of mortality by 12% [OR 0.88, 95% CI 0.82-0.95 (p<0.05)]. The use of ≥30 mL/Kg fluid bolus did not increase the odds of mechanical ventilation [OR 0.99, 95% CI 0.93-1.05 (p = 0.78)]. In subgroup analysis, the use of ≥30 mL/Kg fluid bolus decreased the chances of mortality by 5% [OR 0.95, 95% CI 0.90-0.99, (p<0.05)] and did not increase the odds of mechanical ventilation. The presence of the low ejection fraction did not influence the chance of getting fluid bolus. CONCLUSION The use of ≥30 mL/Kg fluid bolus seems to confer protection against in-hospital mortality and is not associated with increased chances of mechanical ventilation in heart failure patients presenting with severe sepsis or septic shock.
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Affiliation(s)
- Roshan Acharya
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Aakash Patel
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Evan Schultz
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Michael Bourgeois
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Natalie Kandinata
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Rishi Paswan
- Department of Internal Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
| | - Smita Kafle
- RN-BSN Program, Fayetteville State University, Fayetteville, NC, United States of America
| | - Yub Raj Sedhai
- Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Usman Younus
- Department of Critical Care Medicine, Cape Fear Valley Medical Center, Fayetteville, NC, United States of America
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Kang H, Thomas RM. Bacteria and Sepsis: Microbiome to the Rescue? J Clin Med 2021; 10:3578. [PMID: 34441874 PMCID: PMC8396989 DOI: 10.3390/jcm10163578] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 12/13/2022] Open
Abstract
The microbiome is the metagenome of all microbes that live on and within every individual, and evidence for its role in the pathogenesis of a variety of diseases has been increasing over the past several decades. While there are various causes of sepsis, defined as the abnormal host response to infection, the host microbiome may provide a unifying explanation for discrepancies that are seen in septic patient survival based on age, sex, and other confounding factors. As has been the case for other human diseases, evidence exists for the microbiome to control patient outcomes after sepsis. In this review, associative data for the microbiome and sepsis survival are presented with causative mechanisms that may be at play. Finally, clinical trials to manipulate the microbiome in order to improve patient outcomes after sepsis are presented as well as areas of potential future research in order to aid in the clinical treatment of these patients.
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Affiliation(s)
- Hansol Kang
- University of Florida College of Medicine, Gainesville, FL 32610, USA;
| | - Ryan M. Thomas
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA
- Department of Molecular Genetics and Microbiology, University of Florida College of Medicine, Gainesville, FL 32610, USA
- North Florida/South Georgia Veterans Heath System, Gainesville, FL 32608, USA
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15
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He W, Xiao K, Fang M, Xie L. Immune Cell Number, Phenotype, and Function in the Elderly with Sepsis. Aging Dis 2021; 12:277-296. [PMID: 33532141 PMCID: PMC7801284 DOI: 10.14336/ad.2020.0627] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/27/2020] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a form of life-threatening organ dysfunction caused by dysregulated host responses to an infection that can be partly attributed to immune dysfunction. Although sepsis affects patients of all ages, elderly individuals display increased susceptibility and mortality. This is partly due to immunosenescence, a decline in normal immune system function associated with physiological aging that affects almost all cell types in the innate and adaptive immune systems. In elderly patients with sepsis, these alterations in immune cells such as endothelial cells, neutrophils, monocytes, macrophages, natural killer cells, dendritic cells, T lymphocytes, and B lymphocytes, are largely responsible for their poor prognosis and increased mortality. Here, we review recent studies investigating the events affecting both innate and adaptive immune cells in elderly mice and patients with sepsis, including alterations in their number, phenotype, and function, to shed light on possible new therapeutic strategies.
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Affiliation(s)
- Wanxue He
- College of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing, China.
| | - Kun Xiao
- College of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing, China.
| | - Min Fang
- Institute of Microbiology, Chinese Academy of Sciences, Beijing, China.
| | - Lixin Xie
- College of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing, China.
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Schmidt K, Gensichen J, Fleischmann-Struzek C, Bahr V, Pausch C, Sakr Y, Reinhart K, Christian Vollmar H, Thiel P, Scherag A, Gantner* J, M. Brunkhorst* F. Long-Term Survival Following Sepsis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:775-782. [PMID: 33533711 PMCID: PMC7930463 DOI: 10.3238/arztebl.2020.0775] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 04/07/2020] [Accepted: 06/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND There have not yet been any prospective registry studies in Germany with active investigation of the long-term survival of patients with sepsis. METHODS The Jena Sepsis Registry (JSR) included all patients with a diagnosis of sepsis in the four intensive care units of Jena University Hospital from January 2011 to December 2015. Long-term survival 6-48 months after diagnosis was documented by asking the treating general practitioners. The survival times were studied with Kaplan-Meier estimators. Cox regressions were calculated to show associations between possible predictors and survival time. RESULTS 1975 patients with sepsis or septic shock were included. The mean time of observation was 730 days. For 96.4% of the queries to the general practitioners, information on long-term survival was available. Mortality in the intensive care unit was 34% (95% confidence interval [32; 37]), and in-hospital mortality was 45% [42; 47]. The overall mortality six months after diagnosis was 59% [57; 62], the overall mortality 48 months after diagnosis was 74% [72; 78]. Predictors of shorter survival were age, nosocomial origin of sepsis, diabetes, cerebrovascular disease, duration of stay in the intensive care unit, and renal replacement therapy. CONCLUSION The nearly 75% mortality four years after diagnosis indicates that changes are needed both in the acute treatment of patients with sepsis and in their multi-sector long-term care. The applicability of these findings may be limited by their having been obtained in a single center.
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Affiliation(s)
- Konrad Schmidt
- Center for Sepsis Control and Care (CSCC), Jena University Hospital:
- Institute of General Practice and Family Medicine, Jena University Hospital
- Institute of General Practice, Charité–Universitätsmedizin Berlin
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, Jena University Hospital
- Institute of General Practice and Family Medicine, Munich University Hospital, Ludwig-Maximilians-Universität München
| | | | - Viola Bahr
- Center for Clinical Studies, Jena University Hospital
| | - Christine Pausch
- Center for Sepsis Control and Care (CSCC), Jena University Hospital:
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), Leipzig University
| | - Yasser Sakr
- Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital
| | - Konrad Reinhart
- Center for Sepsis Control and Care (CSCC), Jena University Hospital:
- Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital
| | - Horst Christian Vollmar
- Institute of General Practice and Family Medicine, Jena University Hospital
- Institute of General Practice and Family Medicine, Ruhr-University Bochum
| | - Paul Thiel
- Center for Sepsis Control and Care (CSCC), Jena University Hospital:
- Institute of General Practice and Family Medicine, Jena University Hospital
| | - André Scherag
- Center for Sepsis Control and Care (CSCC), Jena University Hospital:
- Institute of Medical Statistics, Computer Science and Data Sciences, Jena University Hospital
| | - Julia Gantner*
- * Joint last authors
- Institute of Medical Statistics, Computer Science and Data Sciences, Jena University Hospital
| | - Frank M. Brunkhorst*
- Center for Sepsis Control and Care (CSCC), Jena University Hospital:
- Center for Clinical Studies, Jena University Hospital
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Strandberg G, Walther S, Agvald Öhman C, Lipcsey M. Mortality after Severe Sepsis and Septic Shock in Swedish Intensive Care Units 2008-2016-A nationwide observational study. Acta Anaesthesiol Scand 2020; 64:967-975. [PMID: 32232853 DOI: 10.1111/aas.13587] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 02/26/2020] [Accepted: 03/09/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recent studies have reported substantially decreased hospital mortality for sepsis, but data are scarcer on outcomes after hospital discharge. We studied mortality up to 1 year in Swedish intensive care unit (ICU) patients with and without sepsis. METHODS Demographic and medical data for all registered adult general ICU patients admitted between 01-01-2008 and 30-09-2016 were retrieved from the Swedish Intensive Care Registry and linked with the National Patient Register for comorbidity data and the Cause of Death Register for death dates. The population was divided in two cohorts; (a) Patients with a diagnosis of severe sepsis or septic shock and (b) All other ICU patients. Crude yearly mortality was calculated, and logistic regression was used to analyse predictors of mortality. RESULTS 28 886 sepsis and 221 941 nonsepsis ICU patients were identified. In the sepsis cohort, in 2008 unadjusted mortality was 32.6% at hospital discharge, 32.7% at 30 days, 39% at 90 days and 46.8% at 365 days. In 2016, mortality was 30.5% at hospital discharge, 31.9% at 30 days and 38% at 90 days. Mortality at 365 days was 45.3% in 2015. Corresponding nonsepsis mortality was 15.4%, 16.2%, 20% and 26% in 2008 and 15.6%, 17.1%, 20.7% and 26.7% in 2016/2015. No consistent decrease in odds of mortality was seen in the adjusted analysis. CONCLUSIONS Mortality in severe sepsis and septic shock is high, with more than one in three patients not surviving three months after ICU admission, and adjusted mortality has not decreased convincingly in Sweden 2008-2016. TRIAL REGISTRATION The study was registered prospectively, ClinicalTrials.gov ID: NCT03489447.
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Affiliation(s)
- Gunnar Strandberg
- Cardiothoracic Surgery and Anaesthesiology Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - Sten Walther
- Department of Cardiothoracic Anaesthesia and Intensive Care Division of Cardiovascular Medicine Department of Medical and Health Sciences Linköping University Hospital Linköping University Linköping Sweden
| | - Christina Agvald Öhman
- Anaesthesiology and Intensive Care Karolinska University Hospital Huddinge Stockholm Sweden
| | - Miklós Lipcsey
- Hedenstierna Laboratory, Anaesthesiology and Intensive Care Department of Surgical Sciences Uppsala University Uppsala Sweden
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Tanner II A, Jarvis S, Orlando A, Nwafo N, Madayag R, Roberts Z, Corrigan C, Carrick M, Bourg P, Smith W, Bar-Or D. A three-year retrospective multi-center study on time to surgery and mortality for isolated geriatric hip fractures. J Clin Orthop Trauma 2020; 11:S56-S61. [PMID: 31992918 PMCID: PMC6977169 DOI: 10.1016/j.jcot.2019.12.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 11/20/2019] [Accepted: 12/02/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There are multiple reports on the effect of time to surgery for geriatric hip fractures; it remains unclear if earlier intervention is associated with improved mortality, hospital length of stay (HLOS), or cost. METHODS This was a multi-center retrospective cohort study. Patients (≥65y.) admitted (1/14-1/16) to six level 1 trauma centers for isolated hip fractures were included. Patients were dichotomized into early (≤24 h of admission) or delayed surgery (>24 h). The primary outcome was mortality using the CDC National Death Index. Secondary outcomes included HLOS, complications, and hospital cost. RESULTS There were 1346 patients, 467 (35%) delayed and 879 (65%) early. The early group had more females (70% vs. 61%, p < 0.001) than the delayed group. The delayed group had a median of 2 comorbidities, whereas the early group had 1, p < 0.001. Mortality and complications were not significantly different between groups. After adjustment, the delayed group had no statistically significant increased risk of dying within one year, OR: 1.1 (95% CI:0.8, 1.5), compared to the early group. The average difference in HLOS was 1.1 days longer for the delayed group, when compared to the early group, p-diff<0.001, after adjustment. The average difference in cost for the delayed group was $2450 ($1550, $3400) more expensive per patient, than the early group, p < 0.001. CONCLUSIONS The results of this study provide further evidence that surgery within 24 h of admission is not associated with lower odds of death when compared to surgery after 24 h of admission, even after adjustment. However, a significant decrease in cost and HLOS was observed for early surgery. If causally linked, our data are 95% confident that earlier treatment could have saved a maximum of $1,587,800. Early surgery should not be pursued purely for the motivation of reducing hospital costs. LEVEL OF EVIDENCE Level III.
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Key Words
- AAOS, American Academy of Orthopedic Surgeons
- ACE, angiotensin-converting enzyme
- AIS, Abbreviated Injury Scale
- AOR, adjusted odds ratio
- ASA, American Society of Anesthesiologists
- AUC, area under the curve
- CDC NDI, Centers for Disease Control National Death Index
- CI, confidence interval
- COPD, chronic obstructive pulmonary disease
- Geriatric hip fractures
- HLOS, Hospital Length of Stay
- IQR, interquartile range
- Long-term mortality
- OR, odds ratio
- RR, respiratory rate
- SBP, systolic blood pressure
- SD, standard deviation
- SE, standard error
- TQIP, Trauma Quality Improvement Program
- Time to surgery
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Affiliation(s)
- Allen Tanner II
- Penrose Hospital, 2222 North Nevada Ave, Colorado Springs, CO, 80907, USA
| | | | | | - Nnamdi Nwafo
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO, 80113, USA
| | - Robert Madayag
- St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO, 80228, USA
| | - Zachary Roberts
- Research Medical Center, 2316 East Meyer Blvd, Kansas City, MO, 64132, USA
| | - Chad Corrigan
- Wesley Medical Center, 550 N. Hillside St. Wichita, KS, 67214, USA
| | - Matthew Carrick
- Medical City Plano, 3901 West 15th Street, Plano, TX, 75075, USA
| | - Pamela Bourg
- St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO, 80228, USA
| | - Wade Smith
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO, 80113, USA
| | - David Bar-Or
- ION Research, 383 Corona St. #319, Denver, CO, 80218, USA,Swedish Medical Center, 501 E Hampden Ave, Englewood, CO, 80113, USA,Corresponding author. Swedish Medical Center, 501 E Hampden Ave, Englewood, CO, 80113, USA.
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The New York Sepsis Severity Score: Development of a Risk-Adjusted Severity Model for Sepsis. Crit Care Med 2019; 46:674-683. [PMID: 29206765 DOI: 10.1097/ccm.0000000000002824] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES In accordance with Rory's Regulations, hospitals across New York State developed and implemented protocols for sepsis recognition and treatment to reduce variations in evidence informed care and preventable mortality. The New York Department of Health sought to develop a risk assessment model for accurate and standardized hospital mortality comparisons of adult septic patients across institutions using case-mix adjustment. DESIGN Retrospective evaluation of prospectively collected data. PATIENTS Data from 43,204 severe sepsis and septic shock patients from 179 hospitals across New York State were evaluated. SETTINGS Prospective data were submitted to a database from January 1, 2015, to December 31, 2015. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Maximum likelihood logistic regression was used to estimate model coefficients used in the New York State risk model. The mortality probability was estimated using a logistic regression model. Variables to be included in the model were determined as part of the model-building process. Interactions between variables were included if they made clinical sense and if their p values were less than 0.05. Model development used a random sample of 90% of available patients and was validated using the remaining 10%. Hosmer-Lemeshow goodness of fit p values were considerably greater than 0.05, suggesting good calibration. Areas under the receiver operator curve in the developmental and validation subsets were 0.770 (95% CI, 0.765-0.775) and 0.773 (95% CI, 0.758-0.787), respectively, indicating good discrimination. Development and validation datasets had similar distributions of estimated mortality probabilities. Mortality increased with rising age, comorbidities, and lactate. CONCLUSIONS The New York Sepsis Severity Score accurately estimated the probability of hospital mortality in severe sepsis and septic shock patients. It performed well with respect to calibration and discrimination. This sepsis-specific model provides an accurate, comprehensive method for standardized mortality comparison of adult patients with severe sepsis and septic shock.
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Bad Brains, Bad Outcomes: Acute Neurologic Dysfunction and Late Death After Sepsis. Crit Care Med 2019; 46:1001-1002. [PMID: 29762396 DOI: 10.1097/ccm.0000000000003097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Mačiulienė A, Maleckas A, Kriščiukaitis A, Mačiulis V, Vencius J, Macas A. Predictors of 30-Day In-Hospital Mortality in Patients Undergoing Urgent Abdominal Surgery Due to Acute Peritonitis Complicated with Sepsis. Med Sci Monit 2019; 25:6331-6340. [PMID: 31441459 PMCID: PMC6717438 DOI: 10.12659/msm.915435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis is a life-threatening condition with high morbidity and mortality rate. Identifying early prediction factors of critical situations in intra-abdominal sepsis patients can help reduce mortality rates. This prospective study was carried out to evaluate the association of technically available factors with 30-day in-hospital mortality. Material/Methods There were 67 intra-abdominal sepsis patients included in the study; patients were observed for 30 days postoperatively. The data was processed using SPSS24.0 statistical analysis package. All tests that had a significance level of 0.05 were selected. Results Septic shock in association with increase in age per year showed increase the odds of mortality and prognosed 30-days in hospital mortality correctly in 79% of cases. The observed OR was 12.24 (P<0.001). Multiple logistic regression model 2 for the 30-day mortality identified a combination of septic shock, age (≥70 years), time from peritonitis symptoms to surgery prognose mortality with accuracy of 82%. The most accurate model to prognose 30-day in-hospital mortality included the presents of septic shock, age, time from peritonitis symptoms to surgery, drop of MAP <65 mmHg) post-induction, the odds of mortality 8.86 (P=0.001). Severe hypotension post-induction was more frequent in patients who were not diagnosed with sepsis (P=0.035). Conclusions The present study revealed a simple indicator for the risk for death under diffuse peritonitis patients complicated with sepsis. Septic shock, increase in age per year, peritonitis symptoms lasting more than 30 hours, and severe hypotension post-induction had a negative prognostic value for mortality in patients with intra-abdominal sepsis, and might be a high risk for 30-day mortality.
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Affiliation(s)
- Asta Mačiulienė
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Almantas Maleckas
- Department of General Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Algimantas Kriščiukaitis
- Department of Physics, Mathematics and Biophysics, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vytautas Mačiulis
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Justinas Vencius
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Andrius Macas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Tan TL, Tang YJ, Ching LJ, Abdullah N, Neoh HM. Comparison of Prognostic Accuracy of the quick Sepsis-Related Organ Failure Assessment between Short- & Long-term Mortality in Patients Presenting Outside of the Intensive Care Unit - A Systematic Review & Meta-analysis. Sci Rep 2018; 8:16698. [PMID: 30420768 PMCID: PMC6232181 DOI: 10.1038/s41598-018-35144-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 10/30/2018] [Indexed: 12/29/2022] Open
Abstract
The purpose of this meta-analysis was to compare the ability of the qSOFA in predicting short- (≤30 days or in-hospital mortality) and long-term (>30 days) mortality among patients outside the intensive care unit setting. Studies reporting on the qSOFA and mortality were searched using MEDLINE and SCOPUS. Studies were included if they involved patients presenting to the ED with suspected infection and usage of qSOFA score for mortality prognostication. Data on qSOFA scores and mortality rates were extracted from 36 studies. The overall pooled sensitivity and specificity for the qSOFA were 48% and 86% for short-term mortality and 32% and 92% for long-term mortality, respectively. Studies reporting on short-term mortality were heterogeneous (Odd ratio, OR = 5.6; 95% CI = 4.6-6.8; Higgins's I2 = 94%), while long-term mortality studies were homogenous (OR = 4.7; 95% CI = 3.5-6.1; Higgins's I2 = 0%). There was no publication bias for short-term mortality analysis. The qSOFA score showed poor sensitivity but moderate specificity for both short and long-term mortality, with similar performance in predicting both short- and long- term mortality. Geographical region was shown to have nominal significant (p = 0.05) influence on qSOFA short-term mortality prediction.
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Affiliation(s)
- Toh Leong Tan
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia.
| | - Ying Jing Tang
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Ling Jing Ching
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Noraidatulakma Abdullah
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Hui-Min Neoh
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
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Karachun AM, Petrov AS, Panayotti LL, Ol'kina AY. [Influence of anastomotic leakage on the long-term outcomes in patients with colorectal cancer]. Khirurgiia (Mosk) 2018:42-46. [PMID: 30199050 DOI: 10.17116/hirurgia201808242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Anastomotic leakage after surgery for colorectal cancer is a widely known factor aggravating immediate outcomes. At the same time, deterioration of oncological results is under much less attention. Long-term consequences of anastomotic leakage and possible mechanism of negative effect of this complication on long-term results are reviewed in the article.
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Affiliation(s)
- A M Karachun
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia
| | - A S Petrov
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia
| | - L L Panayotti
- Petrov National Medical Research Center of Oncology of Healthcare Ministry of Russia, St. Petersburg, Russia
| | - A Yu Ol'kina
- Pavlov First St. Petersburg Medical University of Healthcare Ministry of Russia, St. Petersburg, Russia
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Abou Dagher G, Hajjar K, Khoury C, El Hajj N, Kanso M, Makki M, Mailhac A, Bou Chebl R. Outcomes of patients with systolic heart failure presenting with sepsis to the emergency department of a tertiary hospital: a retrospective chart review study from Lebanon. BMJ Open 2018; 8:e022185. [PMID: 30068620 PMCID: PMC6074621 DOI: 10.1136/bmjopen-2018-022185] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Patients with congestive heart failure (CHF) may be at a higher risk of mortality from sepsis than patients without CHF due to insufficient cardiovascular reserves during systemic infections. The aim of this study is to compare sepsis-related mortality between CHF and no CHF in patients presenting to a tertiary medical centre. DESIGN A single-centre, retrospective, cohort study. SETTING Conducted in an academic emergency department (ED) between January 2010 and January 2015. Patients' charts were queried via the hospital's electronic system. Patients with a diagnosis of sepsis were included. Descriptive analysis was performed on the demographics, characteristics and outcomes of patients with sepsis of the study population. PARTICIPANTS A total of 174 patients, of which 87 (50%) were patients with CHF. PRIMARY AND SECONDARY OUTCOMES The primary outcome of the study was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) and hospital lengths of stay, and differences in interventions between the two groups. RESULTS Patients with CHF had a higher in-hospital mortality (57.5% vs 34.5%). Patients with sepsis and CHF had higher odds of death compared with the control population (OR 2.45; 95% CI 1.22 to 4.88). Secondary analyses showed that patients with CHF had lower instances of bacteraemia on presentation to the ED (31.8% vs 46.4%). They had less intravenous fluid requirements in first 24 hours (2.75±2.28 L vs 3.67±2.82 L, p =0.038), had a higher rate of intubation in the ED (24.2% vs 10.6%, p=0.025) and required more dobutamine in the first 24 hours (16.1% vs 1.1%, p<0.001). ED length of stay was found to be lower in patients with CHF (15.12±24.45 hours vs 18.17±26.13 hours, p=0.418) and they were more likely to be admitted to the ICU (59.8% vs 48.8%, p=0.149). CONCLUSION Patients with sepsis and CHF experienced an increased hospital mortality compared with patients without CHF.
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Affiliation(s)
- Gilbert Abou Dagher
- Department of Emergency Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Karim Hajjar
- Department of Emergency Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Christopher Khoury
- Department of Emergency Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Nadine El Hajj
- Department of Emergency Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Mohammad Kanso
- Department of Emergency Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Maha Makki
- Department of Emergency Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Aurelie Mailhac
- Department of Emergency Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Ralphe Bou Chebl
- Department of Emergency Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
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25
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Current etiology, clinical features and outcomes of bacteremia in older patients with solid tumors. J Geriatr Oncol 2018; 10:246-251. [PMID: 30005979 DOI: 10.1016/j.jgo.2018.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/02/2018] [Accepted: 06/26/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE To assess the etiology, clinical features and outcomes of bacteremia in older patients with solid tumors. METHODS All episodes of bacteremia in hospitalized patients with solid tumors were prospectively collected. Patients aged ≥70 years were compared to patients aged <70 years. Risk factors for case-fatality rates in older patients were identified. RESULTS We compared 217 episodes of bacteremia involving older patients and 525 occurring in younger patients. Older patients had more frequently other comorbidities, but were less commonly neutropenic and carried less frequently central venous catheters. Bacteremia from an abdominal source was more common in patients ≥70, whereas an endogenous source and catheter-related infection were less frequently observed. Streptococcus bovis group (3.7% vs. 0.8%, p = .01) and Listeria monocytogenes (4.6% vs. 1.9%, p = .04) were more common in older patients, whereas coagulase-negative staphylococci were less frequently found (1.4% vs. 5.3% p = .01). Infection due to multi-drug resistant (MDR) strains was significantly higher in older patients (17.1% vs. 10.9%, p = .02), who in addition, presented higher overall mortality (35.4% vs 27.7%, p = .04). In older patients, lung tumor, neutropenia, and low grade fever were associated with early mortality, whereas comorbidities, corticosteroids, septic shock and inadequate empirical antibiotic therapy were associated with overall mortality. CONCLUSIONS We identified remarkable differences in the etiology and sources of bacteremia between older and younger cancer patients with bacteremia. Older patients had more frequent infection due to MDR organisms and presented a higher overall mortality. Corticosteroids and inadequate empirical antibiotic therapy are modifiable factors associated with mortality.
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Policardo L, Seghieri G, Gualdani E, Franconi F. Effect of statins in preventing hospitalizations for infections: A population study. Pharmacoepidemiol Drug Saf 2018; 27:878-884. [PMID: 29808503 DOI: 10.1002/pds.4557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/24/2018] [Accepted: 04/13/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE To investigate whether the hospitalization rate for bacterial infections was modified by statin therapy in a population retrospectively followed up, over years 2011 to 2015. METHODS By using administrative databases, the 5-year hospitalization rate due to bacterial infections in population living in Tuscany, Italy exposed to statin therapy (n = 52,049) was stratified by 5 prescribed daily doses classes (0%-20%, 20%-50%, 50%-80%, 80%-100%, ≥100% of DDD) and subsequently compared with that of a population of untreated individuals (n = 3 300 ,675), matched through a propensity score accounting for all available covariates potentially able to modulate risk of infections such as age, gender, previous hospitalizations for infections, cardiovascular events, previous co-morbidities, diabetes, as well as general practitioners' proactive behaviour of care delivery according to current guidelines. RESULTS Unmatched individuals of each treatment-class had significantly more hospitalizations than controls, while matched treated people, apart from those in class 0% to 20%, had a decrease of hospitalizations, as large as the increase in prescribed drug. Statin effect in reducing hospitalizations translated into a number needed to treat (NNT) ranging across treatment strata from 102 to 54. CONCLUSIONS Compliance to statin prescribed daily doses above the threshold 20% of DDD, along a 5-year follow-up, prevented hospitalizations due to infectious diseases in a large unselected population, after adjusting for covariates able to modulate baseline risk of infections. The NNTs to avoid 1 hospitalization for infections resulted on average not too dissimilar from a value lying between the 95% CI of NNTs previously found for primary prevention of 1 incident coronary ischemic event (72 to 119).
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Affiliation(s)
- Laura Policardo
- Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy
| | - Giuseppe Seghieri
- Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy
| | - Elisa Gualdani
- Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy
| | - Flavia Franconi
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
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Abstract
Sepsis is a common and often devastating medical emergency with a high mortality rate and, in many survivors, long-term morbidity. It is defined as the dysregulated host response to infection resulting in organ dysfunction, and its incidence is increasing as the population ages. However, it is a treatable and potentially reversible condition, especially if identified and treated promptly. A sound understanding of sepsis is crucial for optimal care. Although general guidelines are available for management, here we provide a foundation of understanding to encourage thoughtful, personalised management of sepsis during the acute phase. We provide an overview of the epidemiology, the new Sepsis-3 definitions, pathophysiology, clinical presentations, and investigation and management of sepsis for the non-expert.
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Affiliation(s)
- Robert Tidswell
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
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28
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López-Mestanza C, Andaluz-Ojeda D, Gómez-López JR, Bermejo-Martín JF. Clinical factors influencing mortality risk in hospital-acquired sepsis. J Hosp Infect 2017; 98:194-201. [PMID: 28882641 DOI: 10.1016/j.jhin.2017.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/29/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Identification of factors that confer an increased risk of mortality in hospital-acquired sepsis (HAS) is necessary to help prevent, and improve the outcome of, this condition. AIM To evaluate the clinical characteristics and factors associated with mortality in patients with HAS. METHODS Retrospective study of patients with HAS in a major Spanish Hospital from 2011 to 2015. Data from adults receiving any of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes associated with sepsis were collected. Those fulfilling the SEPSIS-2 definition with no evidence of infection during the first 48 h following hospitalization were included (N = 196). Multivariate analysis was employed to identify the risk factors of mortality. FINDINGS HAS patients were found to have many of the risk factors associated with cardiovascular disease (male sex, ageing, antecedent of cardiac disease, arterial hypertension, dyslipidaemia, smoking habit) and cancer. Vascular disease or chronic kidney disease were associated with 28-day mortality. Time from hospital admission to sepsis diagnosis, and the presence of organ failure were risk factors for 28-day and hospital mortality. Experiencing more than one episode of sepsis increased the risk of hospital mortality. 'Sepsis code' for the early identification of sepsis was protective against hospital mortality. CONCLUSION This study identifies several major factors associated with mortality in patients suffering from HAS. Implementation of surveillance programmes for the early identification and treatment of sepsis translate into a clear benefit.
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Affiliation(s)
- C López-Mestanza
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario de Valladolid, SACYL, Valladolid, Spain.
| | - D Andaluz-Ojeda
- Critical Care Medicine Service, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - J R Gómez-López
- General Surgery Service, Hospital de Medina del Campo, SACYL, Medina del Campo-Valladolid, Spain
| | - J F Bermejo-Martín
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario de Valladolid, SACYL, Valladolid, Spain
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Wang S, Liu X, Chen Q, Liu C, Huang C, Fang X. The role of increased body mass index in outcomes of sepsis: a systematic review and meta-analysis. BMC Anesthesiol 2017; 17:118. [PMID: 28859605 PMCID: PMC5579888 DOI: 10.1186/s12871-017-0405-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 08/16/2017] [Indexed: 12/18/2022] Open
Abstract
Background The role of increased body mass index (BMI) in sepsis is controversial. We aimed to evaluate the associations between overweight (25 kg/m2 < BMI ≤ 29.9 kg/m2), obese (30 kg/m2 < BMI ≤ 39.9 kg/m2) and morbidly obese (BMI > 40 kg/m2) BMIs and outcomes in septic patients. Methods We searched the PubMed, Embase, Web of Science, Cochrane Library and ClinicalTrials.gov databases for studies published by December 1, 2016. Electronic database searches yielded 3713 articles, eight of which were included in this meta-analysis. Data were independently extracted by two reviewers, and a third reviewer participated in making decisions as needed. We used Review Manager to conduct the analysis, and the outcomes were reported with odds ratios (ORs) or mean differences (MDs). The primary outcome was mortality, and the secondary outcome was length of stay (LOS) in the intensive care unit (ICU) or the hospital. Results Data from eight studies involving a total of 9696 patients were pooled in our final analysis. Compared with patients with normal BMI (18.5 kg/m2 < BMI ≤ 24.9 kg/m2), patients with BMI ≥ 25 kg/m2 exhibited decreased mortality (OR 0.81; 95% confidence interval (CI), 0.74–0.89, P < 0.0001). In subgroup analysis, compared with normal-weight patients, overweight patients had lower mortality (OR 0.87; 95% CI 0.77–0.97, P = 0.02), whereas obese (OR 0.89, 95% CI 0.72–1.10, P = 0.29) and morbidly obese (OR 0.64, 95% CI 0.38–1.08, P = 0.09) patients did not exhibit significantly reduced mortality. Conclusions In sepsis cases, overweight, but not obesity or morbid obesity, was associated with lower mortality. Further prospective studies are needed to clarify this relationship. Electronic supplementary material The online version of this article (doi:10.1186/s12871-017-0405-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sicong Wang
- Department of Anesthesiology and Intensive Care Medicine, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310003, China.,Department of Anesthesia, Ningbo First Hospital, Ningbo, 315010, China
| | - Xu Liu
- Department of Intensive Care Medicine, the Affiliated Hospital of Guizhou Medical University, Guizhou, 550000, China
| | - Qixing Chen
- Clinical Research Center, Children's Hospital, School of Medicine, Zhejiang University, Hangzhou, 310052, China
| | - Can Liu
- Department of Anesthesiology and Intensive Care Medicine, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Changshun Huang
- Department of Anesthesia, Ningbo First Hospital, Ningbo, 315010, China.
| | - Xiangming Fang
- Department of Anesthesiology and Intensive Care Medicine, the First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, 310003, China.
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Laudanski K, Lapko N, Zawadka M, Zhou BX, Danet-Desnoyers G, Worthen GS. The clinical and immunological performance of 28 days survival model of cecal ligation and puncture in humanized mice. PLoS One 2017; 12:e0180377. [PMID: 28715505 PMCID: PMC5513410 DOI: 10.1371/journal.pone.0180377] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 06/14/2017] [Indexed: 12/29/2022] Open
Abstract
Sepsis triggers a coordinated and thorough immune system response with long-term unfavorable sequelae after the initial insult. Long-term recovery from sepsis has garnered increasing attention recently, but a lack of suitable animal models impairs progress in this area. Our study, therefore, aimed to address the performance of the immune system in a survivable model of sepsis (cecal ligation and sepsis; CLP) for up to 28 d after the initial injury in humanized mice. Our model mimics human sepsis with weight loss and post-sepsis hypothermia. Within the first 7 d of sepsis, the M1 inflammatory cell subtype predominated, as evidenced by increased CD16 expression, but at 28 d, a mixed population of M1 and M2 inflammatory cells emerged, as evidenced by increased secretion of transforming growth factor TGFβ and CD206 expression. This change was accompanied by normalized production of interleukin (IL)-6, tumor necrosis factor TNFα and IL-10 at 28 d. Furthermore, the ability of MO to become regulatory DC or the frequency of endogenous DC were severely affected at 28 days. Thus, sepsis results in profound and persistent changes in the function of myeloid cells up to 28 days after CLP demonstrating the persistence of the new acquired immunological features long after resolution of the sepsis.
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Affiliation(s)
- Krzysztof Laudanski
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA. United States of America
| | - Natalia Lapko
- Faculty of Medicine, Ivano-Frankivsk Medical Institute, Ivano-Frankivsk, Ukraine
| | - Mateusz Zawadka
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Benjamin X. Zhou
- Technical College of New Jersey. Ewing, NJ. United States of America
| | - Gwenn Danet-Desnoyers
- Department of Medicine, University of Pennsylvania, Philadelphia, PA. United States of America
| | - George S. Worthen
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA. United States of America
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Policardo L, Seghieri G, Anichini R, Francesconi P. Effect of statins on hospitalization risk of bacterial infections in patients with or without diabetes. Acta Diabetol 2017; 54:669-675. [PMID: 28421335 DOI: 10.1007/s00592-017-0990-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/31/2017] [Indexed: 01/09/2023]
Abstract
AIMS To investigate whether statins reduce the risk to first hospitalization of bacterial infections, in patients with or without diabetes taking into account prior or incident comorbidities. METHODS By using administrative databases, the effect of current statin use was measured on the risk of first hospitalizations due to bacterial infections in people living in Tuscany, Italy, in the period January 1, 2011-December 31, 2015, after excluding those with previous statins use. Population was stratified as with (n = 128,207) or without diabetes (n = 3,304,906), and the hospitalization risk was analyzed by a Cox proportional hazards regression analysis after adjusting for age, gender, previous comorbidities, chronic renal failure, and prior or incident cardiovascular diseases. RESULTS During the 5-year follow-up, 31,543 hospitalizations for bacterial infections were observed: 2.08(2.06-2.10) per 1000 person-year in non-diabetic and 5679: 9.13(8.94-9.32) per 1000 person-year in diabetic population. Diabetes conferred a greater risk of hospitalizations, independently from confounders [adjusted HR (95% CI) 2.04 (1.97-2.10); P < 0.0001]. Statin use decreased the risk by about 2.5% for each one month of therapy, at the same extent in subjects with or without diabetes, after adjusting for all covariates. CONCLUSIONS In this population, diabetes was associated by a twofold increase in the 5-year risk of hospitalizations for bacterial infections. Statin use decreased this risk to a same extent in subjects without or with diabetes, after adjusting for main confounders including comorbidities, and previous or incident cardiovascular events.
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Affiliation(s)
- Laura Policardo
- Epidemiology Unit, Agenzia Regionale Sanità Toscana, Via Pietro Dazzi 1, 50141, Florence, Italy
| | - Giuseppe Seghieri
- Epidemiology Unit, Agenzia Regionale Sanità Toscana, Via Pietro Dazzi 1, 50141, Florence, Italy.
| | | | - Paolo Francesconi
- Epidemiology Unit, Agenzia Regionale Sanità Toscana, Via Pietro Dazzi 1, 50141, Florence, Italy
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Cranendonk DR, van Vught LA, Wiewel MA, Cremer OL, Horn J, Bonten MJ, Schultz MJ, van der Poll T, Wiersinga WJ. Clinical Characteristics and Outcomes of Patients With Cellulitis Requiring Intensive Care. JAMA Dermatol 2017; 153:578-582. [PMID: 28296993 DOI: 10.1001/jamadermatol.2017.0159] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Cellulitis is a commonly occurring skin and soft tissue infection and one of the most frequently seen dermatological diseases in the intensive care unit (ICU). However, clinical characteristics of patients with cellulitis requiring intensive care treatment are poorly defined. Necrotizing fasciitis is often confused for cellulitis at initial presentation and is considered to be more severe and thus has previously been described in more detail. Objective To describe the clinical presentation and outcomes of patients with ICU-necessitating cellulitis and to compare them with patients with necrotizing fasciitis. Design, Setting, and Participants This prospective cohort study includes all ICU admissions from 2 tertiary hospitals in the Netherlands. Of 2562 sepsis admissions, 101 had possible, probable, or definite cellulitis or soft tissue infections. Retrospective review identified severe cellulitis was the reason for ICU admission in 23 patients, necrotizing fasciitis in 31 patients, and other diagnoses in 47 patients. Main Outcomes and Measures Patient and disease characteristics, cultured pathogens, lengths of stay, and short-term and long-term mortality. Results Overall, 54 patients with cellulitis (n = 23; mean [SD] age, 57.2 [17.7] years) or necrotizing fasciitis (n = 31; mean [SD] age, 54.3 [13.5]) were included in this study. Patients with cellulitis were found to be less severely ill than patients with necrotizing fasciitis. This is reflected in rates of shock (7 [30.4%] vs 19 [61.3%]; P = .03), need for mechanical ventilation (12 [52.2%] vs 19 [93.5%]; P = .003) and slightly lower mean Sequential Organ Failure Assessment scores (8 vs 10; P = .046). Median (interquartile range [IQR]) Acute Physiology and Chronic Health Evaluation IV scores did not differ significantly (82 [75-98] vs 76 [70-96]; P = .16). Patients with cellulitis had more chronic comorbidities than patients with necrotizing fasciitis (20 [87.0%] vs 17 [54.8%]; P = .02), especially cardiovascular insufficiencies (10 [43.5%] vs 4 [12.9%]; P = .02) and immunodeficiencies (9 [39.1%] vs 3 [9.7%]; P = .02). Among patients with cellulitis and patients with patients with necrotizing fasciitis, Staphylococcus aureus (10 [43.5%] vs 4 [12.9%]; P = .02), Streptococcus pyogenes (2 [8.7%] vs 19 [61.3%]; P < .001) and Escherichia coli (4 [17.4%] vs 5 [16.2%]; P = .90) were the most frequently observed pathogens. Median (IQR) length of ICU stay was shorter for patients with cellulitis vs patients with necrotizing fasciitis (3 [2-5] vs 5 [3-11]; P = .01), while median (IQR) hospital length of stay did not differ significantly (22 [10.25-32] vs 36 [14.25-40]; P = .16); and the in-hospital mortality rate (26.1% vs 22.6%, P > .99) and 90-day mortality rate (30.4% vs 22.6%; P = .54) were similar. Conclusions and Relevance Patients with cellulitis patients are seldom admitted to the ICU. However, while these patients are less critically ill on admission than patients with necrotizing fasciitis, they have more chronic comorbidities and most notably similar short-term and long-term mortality. Trial Registration clinicaltrials.gov Identifier: NCT01905033.
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Affiliation(s)
- Duncan R Cranendonk
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands2Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands3Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Lonneke A van Vught
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands2Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Maryse A Wiewel
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands2Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc J Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands2Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands3Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands2Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands3Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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GYM score: 30-day mortality predictive model in elderly patients attended in the emergency department with infection. Eur J Emerg Med 2017; 24:183-188. [DOI: 10.1097/mej.0000000000000321] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Barrett O, Abramovich E, Dreiher J, Novack V, Abu-Shakra M. Short- and long-term mortality due to sepsis in patients with rheumatoid arthritis. Rheumatol Int 2017; 37:1021-1026. [PMID: 28286904 DOI: 10.1007/s00296-017-3694-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 03/02/2017] [Indexed: 11/28/2022]
Abstract
Severe infections and sepsis are common among patients with rheumatoid arthritis (RA) and are associated with increased morbidity and mortality risks. To determine whether RA is an independent risk factor for short- and long-term mortality in patients admitted to an Intensive Care Unit (ICU) with sepsis. A retrospective age- and sex-matched cohort study, based on data of the SEPSIS-ISR Registry, an ongoing study that collects data on all patients admitted with the diagnosis of sepsis to the ICUs of 7 large hospitals during the period 2002-2012. The primary outcomes of the study were the 30-day and 3-years survival rates. A total of 124 RA patients and 248 non-RA patients (mean age 71 years; 64.5% female) were included. Primary site of infection as well as pathogens distributions were similar between the two groups. Severe sepsis and septic shock were diagnosed in 92% vs. 84% (p = 0.03) and 50% versus 39% (p = 0.06) of the RA patients and non-RA, respectively. 30-day survival rates were similar between groups, whereas 3-year survival rate in 30-day survivors was significantly lower among RA patients (34.9%) compared to non-RA patients (55.7%) (p = 0.01). In multivariate Cox proportional hazards regression, RA was found to be a significant independent risk factor for 3-year mortality in 30-day survivors (hazard ratio 1.63 95% confidence interval 1.03-1.63; p = 0.04). RA is an independent risk factor for 3-year mortality, but not short-term mortality following ICU admission with sepsis.
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Affiliation(s)
- Orit Barrett
- Department of Medicine D, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Ella Abramovich
- Department of Medicine D, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | | | - Victor Novack
- Department of Medicine D, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Mahmoud Abu-Shakra
- Department of Medicine D, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel. .,Rheumatic Diseases Unit, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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Vallet H, Riou B, Boddaert J. [Elderly patients and intensive care: Systematic review and geriatrician's point of view]. Rev Med Interne 2017; 38:760-765. [PMID: 28215925 DOI: 10.1016/j.revmed.2017.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 01/12/2017] [Accepted: 01/23/2017] [Indexed: 11/29/2022]
Abstract
The global population is aging and intensive care unit admission rate of elderly patients is dramatically increasing. The objective of this review is to provide an overview of the literature about the management of elderly patients in intensive care unit and more specifically about epidemiology, admission criteria, mortality, functional prognosis and ethical aspects. We also discuss the data on cardiorespiratory arrest, shock, acute respiratory failure and delirium. The mortality rate of patients over 80 years old in intensive care unit can reach up to 70% at 1year, but is dependent on many factors, such as comorbidities or frailty. Above all, more than half of elderly patients recover their long-term autonomy. Their quality of life is comparable to that of the same age population. Considering that the first 3months after an intensive care unit stay are the most decisive in terms of vital and functional prognosis, we will discuss strategies to improve care through the creation of dedicated intensive care-geriatrics networks.
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Affiliation(s)
- H Vallet
- Unité périopératoire gériatrique, service de gériatrie, hôpitaux universitaires Pitié-Salpêtrière-Charles-Foix, DHU FAST, AP-HP, Paris, France; UMR Inserm 1135, Sorbonne universités, UPMC université Paris 6, Paris, France.
| | - B Riou
- UMR Inserm 1166, IHU ICAN, Sorbonne universités, UPMC université Paris 6, Paris, France; Service d'accueil des urgences, hôpitaux universitaires Pitié-Salpêtrière-Charles-Foix, DHU FAST, AP-HP, Paris, France
| | - J Boddaert
- Unité périopératoire gériatrique, service de gériatrie, hôpitaux universitaires Pitié-Salpêtrière-Charles-Foix, DHU FAST, AP-HP, Paris, France; UMR Inserm 1166, UMR CNRS 8256, Sorbonne universités, UPMC université Paris 6, Paris, France
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Negret-Delgado MDP, Puentes-Corredor S, Oliveros H, Poveda-Henao CM, Pareja-Navarro PA, Boada-Becerra NA. Adherence to the guidelines for the management of severe sepsis and septic shock in patients over 65 years of age admitted to the ICU. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rcae.2016.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Adherencia a la guía de manejo de sepsis severa y choque séptico en pacientes mayores de 65 años que ingresan a UCI. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rca.2016.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Abstract
Severe sepsis may be underrecognized in older adults. Therefore, the purpose of this article is to review special considerations related to early detection of severe sepsis in older adults. Normal organ changes attributed to aging may delay early detection of sepsis at the time when interventions have the greatest potential to improve patient outcomes. Systems are reviewed for changes. For example, the cardiovascular system may have a limited or absent compensatory response to inflammation after an infectious insult, and the febrile response and recruitment of white blood cells may be blunted because of immunosenescence in aging. Three of the 4 hallmark responses (temperature, heart rate, and white blood cell count) to systemic inflammation may be diminished in older adults as compared with younger adults. It is important to consider that older adults may not always manifest the typical systemic inflammatory response syndrome. Atypical signs such as confusion, decreased appetite, and unsteady gait may occur before sepsis related organ failure. Systemic inflammatory response syndrome criteria and a comparison of organ failure criteria were reviewed. Mortality rates in sepsis and severe sepsis remain high and are often complicated by multiple organ failures. As the numbers of older adults increase, early identification and prompt treatment is crucial in improving patient outcomes.
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Adherence to the guidelines for the management of severe sepsis and septic shock in patients over 65 years of age admitted to the ICU☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1097/01819236-201644040-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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40
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The Effects of Guided Imagery on Patients Being Weaned from Mechanical Ventilation. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2015; 2015:802865. [PMID: 26640501 PMCID: PMC4657064 DOI: 10.1155/2015/802865] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 10/19/2015] [Accepted: 10/21/2015] [Indexed: 11/17/2022]
Abstract
The study purpose was to assess the effects of guided imagery on sedation levels, sedative and analgesic volume consumption, and physiological responses of patients being weaned from mechanical ventilation. Forty-two patients were selected from two community acute care hospitals. One hospital served as the comparison group and provided routine care (no intervention) while the other hospital provided the guided imagery intervention. The intervention included two sessions, each lasting 60 minutes, offered during morning weaning trials from mechanical ventilation. Measurements were recorded in groups at baseline and 30- and 60-minute intervals and included vital signs and Richmond Agitation-Sedation Scale (RASS) score. Sedative and analgesic medication volume consumption were recorded 24 hours prior to and after the intervention. The guided imagery group had significantly improved RASS scores and reduced sedative and analgesic volume consumption. During the second session, oxygen saturation levels significantly improved compared to the comparison group. Guided imagery group had 4.88 less days requiring mechanical ventilation and 1.4 reduction in hospital length of stay compared to the comparison group. Guided imagery may be complementary and alternative medicine (CAM) intervention to provide during mechanical ventilation weaning trials.
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Huang CT, Tsai YJ, Tsai PR, Yu CJ, Ko WJ. Epidemiology and Outcome of Severe Sepsis and Septic Shock in Surgical Intensive Care Units in Northern Taiwan. Medicine (Baltimore) 2015; 94:e2136. [PMID: 26632737 PMCID: PMC5059006 DOI: 10.1097/md.0000000000002136] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Severe sepsis remains the leading cause of mortality in the critically ill. Local epidemiological studies on sepsis are of paramount importance to increase our knowledge about sepsis features and to improve patient care and prognosis.Adult patients (≥20 years) admitted to the surgical intensive care units with severe sepsis or septic shock from 2009 to 2010 were retrospectively retrieved and analyzed. The primary outcome of interest was 28-day mortality.Of 7795 admissions, 536 (6.9%) patients had severe sepsis. The most common sites of infection were the respiratory tract (38%) and abdomen (33%). Gram-negative bacteria, particularly Klebsiella pneumoniae (8.6%) and Escherichia coli (6.0%), were the major infecting micro-organisms, responsible for approximately two-thirds of the severe sepsis episodes. The overall 28-day mortality rate was 61%, and a higher sequential organ failure assessment score and the use of mechanical ventilation were independently associated with a worse outcome.Admissions with severe sepsis are not uncommon and are associated with substantial 28-day mortality in surgical intensive care units in northern Taiwan. Establishment and optimization of each institutional sepsis care standard to improve the outcome of sepsis are warranted.
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Affiliation(s)
- Chun-Ta Huang
- From the Department of Traumatology, National Taiwan University Hospital (C-TH); Department of Internal Medicine, National Taiwan University Hospital (C-TH, C-JY); Graduate Institute of Clinical Medicine, National Taiwan University, Taipei, Taiwan (C-TH); School of Medicine, College of Medicine, Fu-Jen Catholic University, New Taipei (Y-JT); and Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan (P-RT,W-JK)
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Sehgal V, Bajwa SJS, Consalvo JA, Bajaj A. Clinical conundrums in management of sepsis in the elderly. J Transl Int Med 2015; 3:106-112. [PMID: 27847897 PMCID: PMC4936459 DOI: 10.1515/jtim-2015-0010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In 2012, surviving sepsis campaign came out with updated international guidelines for management of severe sepsis and septic shock. Paradoxically, there are no specific guidelines for management of sepsis in the elderly, although the elderly are more predisposed to sepsis, and morbidity and mortality related to sepsis. Sepsis in the elderly is, more often than not, complicated by clinical conundrums such as congestive heart failure (CHF), atrial fibrillation (AF), chronic kidney disease (CKD), acute kidney injury (AKI), delirium, dementia, ambulatory dysfunction, polypharmacy, malglycemia, nutritional deficiencies, and antibiotic resistance. Also, with recurrent admissions to the hospital and widespread use of antibiotics, the elderly are more susceptible to Clostridium difficile colitis.
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Affiliation(s)
- Vishal Sehgal
- Department of Internal Medicine, The Common Wealth Medical College, Scranton, PA 18510, USA
| | - Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care Medicine, Gian Sagar Medical College, Banur, Patiala, Punjab, India
| | - John A Consalvo
- Chairman Emergency Medicine, Regional hospital of Scranton, PA, USA
| | - Anurag Bajaj
- Department of Internal Medicine, WCGME, SCRANTON, PA, USA
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Palomba H, Corrêa TD, Silva E, Pardini A, Assuncao MSCD. Comparative analysis of survival between elderly and non-elderly severe sepsis and septic shock resuscitated patients. ACTA ACUST UNITED AC 2015; 13:357-63. [PMID: 26313436 PMCID: PMC4943779 DOI: 10.1590/s1679-45082015ao3313] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 05/21/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To compare outcomes between elderly (≥65 years old) and non-elderly (<65 years old) resuscitated severe sepsis and septic shock patients and determine predictors of death among elderly patients. METHODS Retrospective cohort study including 848 severe sepsis and septic shock patients admitted to the intensive care unit between January 2006 and March 2012. RESULTS Elderly patients accounted for 62.6% (531/848) and non-elderly patients for 37.4% (317/848). Elderly patients had a higher APACHE II score [22 (18-28)versus 19 (15-24); p<0.001], compared to non-elderly patients, although the number of organ dysfunctions did not differ between the groups. No significant differences were found in 28-day and in-hospital mortality rates between elderly and non-elderly patients. The length of hospital stay was higher in elderly compared to non-elderly patients admitted with severe sepsis and septic shock [18 (10-41)versus 14 (8-29) days, respectively; p=0.0001]. Predictors of death among elderly patients included age, site of diagnosis, APACHE II score, need for mechanical ventilation and vasopressors. CONCLUSION In this study population early resuscitation of elderly patients was not associated with increased in-hospital mortality. Prospective studies addressing the long-term impact on functional status and quality of life are necessary.
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Affiliation(s)
| | | | - Eliézer Silva
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Pera A, Campos C, López N, Hassouneh F, Alonso C, Tarazona R, Solana R. Immunosenescence: Implications for response to infection and vaccination in older people. Maturitas 2015; 82:50-5. [PMID: 26044074 DOI: 10.1016/j.maturitas.2015.05.004] [Citation(s) in RCA: 262] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 05/04/2015] [Accepted: 05/08/2015] [Indexed: 12/19/2022]
Abstract
People aged 60 and older represent over 11% of the world population and it is expected to rise 22% by 2050. Population aging is associated to an increased frequency of age-related diseases including higher susceptibility to infections, cancer, cardiovascular and neurodegenerative diseases. Immunosenescence refers to the decline of the immune system associated to aging. It affects both, innate and adaptive immunity limiting the response to pathogens and to vaccines. The analyses of the immune system in elderly individuals determined several immune signatures constituting an immune risk phenotype that predicts mortality. An inverse CD4/CD8 ratio, loss of naïve T cells, increased numbers of terminally-differentiated T cells and oligoclonal expansions of virus-specific T cells constitute hallmarks of immunosenescence. Natural killer (NK) cells are also found severely altered in the elderly. The contribution of latent cytomegalovirus infection to immunosenescence of T and NK cells has been shown. Considering the worldwide ageing of the population in the next decades, the impact of infections will be a real health problem for older individuals requiring preventive strategies. Thus, further studies are required to analyse the bases of immunosenescence and to establish protocols to overcome the age-associated alterations of the immune response in order to define effective vaccines against those pathogens, such as influenza, contributing to increased morbidity and mortality in the elderly.
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Affiliation(s)
- Alejandra Pera
- Department of Immunology, IMIBIC, Reina Sofia University Hospital, University of Cordoba, REIPI, Cordoba, Spain
| | - Carmen Campos
- Department of Immunology, IMIBIC, Reina Sofia University Hospital, University of Cordoba, REIPI, Cordoba, Spain
| | - Nelson López
- Department of Immunology, IMIBIC, Reina Sofia University Hospital, University of Cordoba, REIPI, Cordoba, Spain
| | - Fakhri Hassouneh
- Department of Immunology, IMIBIC, Reina Sofia University Hospital, University of Cordoba, REIPI, Cordoba, Spain
| | - Corona Alonso
- Department of Immunology, IMIBIC, Reina Sofia University Hospital, University of Cordoba, REIPI, Cordoba, Spain
| | | | - Rafael Solana
- Department of Immunology, IMIBIC, Reina Sofia University Hospital, University of Cordoba, REIPI, Cordoba, Spain.
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Chang PH, Yeh KY, Huang JS, Chen EYC, Yang SW, Wang CH. Chemoradiotherapy in elderly patients with advanced head and neck cancer under intensive nutritional support. Asia Pac J Clin Oncol 2014; 11:228-35. [PMID: 25535674 DOI: 10.1111/ajco.12323] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2014] [Indexed: 01/25/2023]
Abstract
AIM To evaluate treatment tolerance, toxicities and survival in elderly patients with advanced head and neck cancer who received inpatient-based intensive nutritional support with concurrent chemoradiotherapy in comparison with younger patients undergoing the same treatment. METHODS We retrospectively analyzed the records of 126 stage III, IVA and IVB head and neck cancer patients who were treated with concurrent chemoradiotherapy between 2007 and 2009 under an inpatient-based nutritional support program. The clinical characteristics, treatment tolerance, toxicities and survival of patients older than 65 years were compared with those of identically treated patients younger than 65 years. RESULTS There were 21 patients older than 65 years and 105 patients younger than 65 years. Clinical characteristics and treatment toxicities were similar between the groups, except that the elderly were less likely to tolerate cisplatin, experienced more weight loss, required more feeding tube support and tended to have >grade 3 hematological toxicities and to develop sepsis during the period of chemoradiotherapy. The 1- and 2-year disease-free survival and disease-specific survival rates were nearly identical. CONCLUSION Age alone should not be considered a contraindication to aggressive chemoradiotherapy for advanced head and neck cancer. Older patients require more careful multidisciplinary assessment of their supportive care needs to ensure successful completion of treatment and avoid further treatment-related toxicity.
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Affiliation(s)
- Pei-Hung Chang
- Division of Hematology/Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung and Chang Gung University, College of Medicine, Taiwan
| | - Kun-Yun Yeh
- Division of Hematology/Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung and Chang Gung University, College of Medicine, Taiwan
| | - Jen-Seng Huang
- Division of Hematology/Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung and Chang Gung University, College of Medicine, Taiwan
| | - Eric Yen-Chao Chen
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Keelung and Chang Gung University, College of Medicine, Taiwan
| | - Shih-Wei Yang
- Department of Otolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital, Keelung and Chang Gung University, College of Medicine, Taiwan
| | - Cheng-Hsu Wang
- Division of Hematology/Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung and Chang Gung University, College of Medicine, Taiwan.,Cancer Center, Chang Gung Memorial Hospital, Keelung, Taiwan
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Long term outcomes following hospital admission for sepsis using relative survival analysis: a prospective cohort study of 1,092 patients with 5 year follow up. PLoS One 2014; 9:e112224. [PMID: 25486241 PMCID: PMC4259299 DOI: 10.1371/journal.pone.0112224] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 10/10/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Sepsis is a leading cause of death in intensive care units and is increasing in incidence. Current trials of novel therapeutic approaches for sepsis focus on 28-day mortality as the primary outcome measure, but excess mortality may extend well beyond this time period. METHODS We used relative survival analysis to examine excess mortality in a cohort of 1,028 patients admitted to a tertiary referral hospital with sepsis during 2007-2008, over the first 5 years of follow up. Expected survival was estimated using the Ederer II method, using Australian life tables as the reference population. Cumulative and interval specific relative survival were estimated by age group, sex, sepsis severity and Indigenous status. RESULTS Patients were followed for a median of 4.5 years (range 0-5.2). Of the 1028 patients, the mean age was 46.9 years, 52% were male, 228 (22.2%) had severe sepsis and 218 (21%) died during the follow up period. Mortality based on cumulative relative survival exceeded that of the reference population for the first 2 years post admission in the whole cohort and for the first 3 years in the subgroup with severe sepsis. Independent predictors of mortality over the whole follow up period were male sex, Indigenous Australian ethnicity, older age, higher Charlson Comorbidity Index, and sepsis-related organ dysfunction at presentation. CONCLUSIONS The mortality rate of patients hospitalised with sepsis exceeds that of the general population until 2 years post admission. Efforts to improve outcomes from sepsis should examine longer term outcomes than the traditional primary endpoints of 28-day and 90-day mortality.
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Sodhi K, Singla MK, Shrivastava A, Bansal N. Do Intensive Care Unit treatment modalities predict mortality in geriatric patients: An observational study from an Indian Intensive Care Unit. Indian J Crit Care Med 2014; 18:789-795. [PMID: 25538413 PMCID: PMC4271278 DOI: 10.4103/0972-5229.146312] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Ageing being a global phenomenon, increasing number of elderly patients are admitted to Intensive Care Units (ICU). Hence, there is a need for continued research on outcomes of ICU treatment in the elderly. OBJECTIVES Examine age-related difference in outcomes of geriatric ICU patients. Analyze ICU treatment modalities predicting mortality in patients >65 years of age. MATERIALS AND METHODS A retrospective observational study was conducted in 2317 patients admitted in a multi-specialty ICU of a tertiary care hospital over 2-year study period from January 1, 2011 to December 31, 2012. A clinical database was collected which included age, sex, specialty under which admitted, APACHE-II and SOFA scores, patient outcome, average length of ICU stay, and the treatment modalities used in ICU including mechanical ventilation, inotropes, hemodialysis, and tracheostomy. Patients were divided into two groups: <65 years (Control group) and >65 years (Geriatric age group). RESULTS The observed overall ICU mortality rate in the study population was 19.6%; no statistical difference was observed between the control and geriatric age group in overall mortality (P > 0.05). Mechanical ventilation (P = 0.003, odds ratio [OR] =0.573, 95% confidence interval [CI] =0.390-0.843) and use of inotropes (P = 0.018, OR = 0.661, 95% CI = 0.456-0.958) were found to be predictors of mortality in elderly population. On multivariate analysis, inotropic support was found to be an independent ICU treatment modality predicting mortality in the geriatric age group (β coefficient = 1.221, P = 0.000). CONCLUSION Intensive Care Unit mortality rates increased in the geriatric population requiring mechanical ventilation and inotropes during ICU stay. Only inotropic support could be identified as independent risk factor for mortality.
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Affiliation(s)
- Kanwalpreet Sodhi
- From: Department of Critical Care, SPS Apollo Hospitals, Ludhiana, Punjab, India
| | - Manender Kumar Singla
- Department of Anaesthesia and Critical Care and Statistician, SPS Apollo Hospitals, Ludhiana, Punjab, India
| | - Anupam Shrivastava
- Department of Anaesthesia and Critical Care and Statistician, SPS Apollo Hospitals, Ludhiana, Punjab, India
| | - Namita Bansal
- Department of Quality Assurance, SPS Apollo Hospitals, Ludhiana, Punjab, India
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Starr ME, Saito H. Sepsis in old age: review of human and animal studies. Aging Dis 2014; 5:126-36. [PMID: 24729938 PMCID: PMC3966671 DOI: 10.14336/ad.2014.0500126] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 12/17/2013] [Accepted: 12/18/2013] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a serious problem among the geriatric population as its incidence and mortality rates dramatically increase with advanced age. Despite a large number of ongoing clinical and basic research studies, there is currently no effective therapeutic strategy that rescues elderly patients with severe sepsis. Recognition of this problem is relatively low as compared to other age-associated diseases. The disparity between clinical and basic studies is a problem, and this is likely due, in part, to the fact that most laboratory animals used for sepsis research are not old while the majority of sepsis cases occur in the geriatric population. The objective of this article is to review recent epidemiological studies and clinical observations, and compare these with findings from basic laboratory studies which have used aged animals in experimental sepsis.
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Affiliation(s)
- Marlene E Starr
- Department of Surgery, Lexington, KY 40536, USA
- Markey Cancer Center University of Kentucky, Lexington, KY 40536, USA
| | - Hiroshi Saito
- Department of Surgery, Lexington, KY 40536, USA
- Department of Physiology, Lexington, KY 40536, USA
- Markey Cancer Center University of Kentucky, Lexington, KY 40536, USA
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