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Rosa RG, Teixeira C, Piva S, Morandi A. Anticipating ICU discharge and long-term follow-up. Curr Opin Crit Care 2024; 30:157-164. [PMID: 38441134 DOI: 10.1097/mcc.0000000000001136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW This review aims to summarize recent literature findings on long-term outcomes following critical illness and to highlight potential strategies for preventing and managing health deterioration in survivors of critical care. RECENT FINDINGS A substantial number of critical care survivors experience new or exacerbated impairments in their physical, cognitive or mental health, commonly named as postintensive care syndrome (PICS). Furthermore, those who survive critical illness often face an elevated risk of adverse outcomes in the months following their hospital stay, including infections, cardiovascular events, rehospitalizations and increased mortality. These findings underscore the need for effective prevention and management of long-term health deterioration in the critical care setting. While robust evidence from well designed randomized clinical trials is limited, potential interventions encompass sedation limitation, early mobilization, delirium prevention and family presence during intensive care unit (ICU) stay, as well as multicomponent transition programs (from ICU to ward, and from hospital to home) and specialized posthospital discharge follow-up. SUMMARY In this review, we offer a concise overview of recent insights into the long-term outcomes of critical care survivors and advancements in the prevention and management of health deterioration after critical illness.
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Affiliation(s)
| | - Cassiano Teixeira
- Internal Medicine Department, Hospital Moinhos de Vento
- Critical Care Department, Hospital de Clínicas de Porto Alegre, Porto Alegre (RS), Brazil
| | - Simone Piva
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia
| | - Alessandro Morandi
- Rehabilitation and Intermediate Care, Azienda Speciale Cremona Solidale, Cremona, Italy
- REFiT Bcn Research Group, Parc Sanitari Pere Virgili and Vall d'Hebrón Institut de Recerca (VHIR), Barcelona, Spain
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2
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Giamarellos-Bourboulis EJ. Immune-mediated inflammatory diseases as long-term sepsis complications: Long-term persistence of host dysregulation? J Intern Med 2024; 295:123-125. [PMID: 38091384 DOI: 10.1111/joim.13761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
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Garrity K, Gaw S, Blewitt A, Canon P, McCall P, McPeake J. Cardiac dysfunction in survivors of sepsis: a scoping review. Open Heart 2023; 10:e002454. [PMID: 38065588 PMCID: PMC10711866 DOI: 10.1136/openhrt-2023-002454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 11/07/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Sepsis is associated with an increased risk of adverse cardiovascular events in a magnitude comparable to other major cardiovascular risk factors. Sepsis is one of the most common reasons for intensive care admission and survivors often have significant functional limitations following discharge. However, it is not clear to what extent chronic cardiovascular dysfunction might mediate these functional impairments, or how we might screen and manage these patients at risk of chronic cardiovascular disease. We conducted a scoping review to map existing evidence and identify research gaps relating to cardiovascular dysfunction following sepsis. METHODS We conducted a systematic search of MEDLINE, Embase and CINAHL databases using a concept, context, population (CoCoPop) framework. Studies examining cardiovascular outcomes or symptoms following an episode of sepsis in adults were included. Data were mapped based on the population assessed, cardiovascular outcomes examined, inclusion of objective measures of cardiac dysfunction such as biomarkers or cardiovascular imaging, or whether cardiovascular symptoms or patient-reported functional outcomes measures were recorded. RESULTS We identified 11 210 articles of which 70 were eligible for full text review and 28 were included in final analysis. Across our dataset, a wide range of incident cardiovascular outcomes were reported in the literature including incidence of congestive heart failure (13/28), arrhythmia (6/28), myocardial infarction (24/28) or cardiovascular death or all-cause mortality (20/28). Only 39% (11/28) of articles reported objective measures of cardiovascular function and only one article related cardiovascular function to functional impairment via patient-reported outcome measures. CONCLUSION There are significant gaps in our understanding of cardiac dysfunction following sepsis . While the research highlights the strong association of sepsis with a variety of adverse cardiovascular outcomes, further prospective work is required to understand the mechanisms that mediate this phenomenon and how we can best identify and manage patients at risk.
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Affiliation(s)
- Kevin Garrity
- University of Glasgow, Glasgow, UK
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | | | | | - Philip McCall
- University of Glasgow, Glasgow, UK
- NHS Golden Jubilee, Glasgow, UK
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Lira Chavez FM, Gartzke LP, van Beuningen FE, Wink SE, Henning RH, Krenning G, Bouma HR. Restoring the infected powerhouse: Mitochondrial quality control in sepsis. Redox Biol 2023; 68:102968. [PMID: 38039825 DOI: 10.1016/j.redox.2023.102968] [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: 10/12/2023] [Revised: 11/07/2023] [Accepted: 11/15/2023] [Indexed: 12/03/2023] Open
Abstract
Sepsis is a dysregulated host response to an infection, characterized by organ failure. The pathophysiology is complex and incompletely understood, but mitochondria appear to play a key role in the cascade of events that culminate in multiple organ failure and potentially death. In shaping immune responses, mitochondria fulfil dual roles: they not only supply energy and metabolic intermediates crucial for immune cell activation and function but also influence inflammatory and cell death pathways. Importantly, mitochondrial dysfunction has a dual impact, compromising both immune system efficiency and the metabolic stability of end organs. Dysfunctional mitochondria contribute to the development of a hyperinflammatory state and loss of cellular homeostasis, resulting in poor clinical outcomes. Already in early sepsis, signs of mitochondrial dysfunction are apparent and consequently, strategies to optimize mitochondrial function in sepsis should not only prevent the occurrence of mitochondrial dysfunction, but also cover the repair of the sustained mitochondrial damage. Here, we discuss mitochondrial quality control (mtQC) in the pathogenesis of sepsis and exemplify how mtQC could serve as therapeutic target to overcome mitochondrial dysfunction. Hence, replacing or repairing dysfunctional mitochondria may contribute to the recovery of organ function in sepsis. Mitochondrial biogenesis is a process that results in the formation of new mitochondria and is critical for maintaining a pool of healthy mitochondria. However, exacerbated biogenesis during early sepsis can result in accumulation of structurally aberrant mitochondria that fail to restore bioenergetics, produce excess reactive oxygen species (ROS) and exacerbate the disease course. Conversely, enhancing mitophagy can protect against organ damage by limiting the release of mitochondrial-derived damage-associated molecules (DAMPs). Furthermore, promoting mitophagy may facilitate the growth of healthy mitochondria by blocking the replication of damaged mitochondria and allow for post sepsis organ recovery through enabling mitophagy-coupled biogenesis. The remaining healthy mitochondria may provide an undamaged scaffold to reproduce functional mitochondria. However, the kinetics of mtQC in sepsis, specifically mitophagy, and the optimal timing for intervention remain poorly understood. This review emphasizes the importance of integrating mitophagy induction with mtQC mechanisms to prevent undesired effects associated with solely the induction of mitochondrial biogenesis.
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Affiliation(s)
- F M Lira Chavez
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, University of Groningen, 9713, GZ Groningen, the Netherlands.
| | - L P Gartzke
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, University of Groningen, 9713, GZ Groningen, the Netherlands
| | - F E van Beuningen
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, University of Groningen, 9713, GZ Groningen, the Netherlands
| | - S E Wink
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, University of Groningen, 9713, GZ Groningen, the Netherlands
| | - R H Henning
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, University of Groningen, 9713, GZ Groningen, the Netherlands
| | - G Krenning
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, University of Groningen, 9713, GZ Groningen, the Netherlands; Sulfateq B.V, Admiraal de Ruyterlaan 5, 9726, GN Groningen, the Netherlands
| | - H R Bouma
- Department of Clinical Pharmacy and Pharmacology, University Medical Centre Groningen, University of Groningen, 9713, GZ Groningen, the Netherlands; Department of Internal Medicine, University Medical Centre Groningen, University of Groningen, 9713, GZ Groningen, the Netherlands
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5
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van der Slikke EC, Beumeler LFE, Holmqvist M, Linder A, Mankowski RT, Bouma HR. Understanding Post-Sepsis Syndrome: How Can Clinicians Help? Infect Drug Resist 2023; 16:6493-6511. [PMID: 37795206 PMCID: PMC10546999 DOI: 10.2147/idr.s390947] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023] Open
Abstract
Sepsis is a global health challenge, with over 49 million cases annually. Recent medical advancements have increased in-hospital survival rates to approximately 80%, but the escalating incidence of sepsis, owing to an ageing population, rise in chronic diseases, and antibiotic resistance, have also increased the number of sepsis survivors. Subsequently, there is a growing prevalence of "post-sepsis syndrome" (PSS). This syndrome includes long-term physical, medical, cognitive, and psychological issues after recovering from sepsis. PSS puts survivors at risk for hospital readmission and is associated with a reduction in health- and life span, both at short and long term, after hospital discharge. Comprehensive understanding of PSS symptoms and causative factors is vital for developing optimal care for sepsis survivors, a task of prime importance for clinicians. This review aims to elucidate our current knowledge of PSS and its relevance in enhancing post-sepsis care provided by clinicians.
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Affiliation(s)
- Elisabeth C van der Slikke
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, 9713GZ, the Netherlands
| | - Lise F E Beumeler
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, 8934AD, the Netherlands
- Department of Sustainable Health, Campus Fryslân, University of Groningen, Groningen, 8911 CE, the Netherlands
| | - Madlene Holmqvist
- Department of Infection Medicine, Skåne University Hospital Lund, Lund, 221 84, Sweden
| | - Adam Linder
- Department of Infection Medicine, Skåne University Hospital Lund, Lund, 221 84, Sweden
| | - Robert T Mankowski
- Department of Physiology and Aging, University of Florida, Gainesville, FL, 32610, USA
| | - Hjalmar R Bouma
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, 9713GZ, the Netherlands
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, 9713GZ, the Netherlands
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Lörstad S, Shekarestan S, Jernberg T, Tehrani S, Åstrand P, Gille-Johnson P, Persson J. First Sampled High-Sensitive Cardiac Troponin T is Associated With One-Year Mortality in Sepsis Patients and 30- to 365-Day Mortality in Sepsis Survivors. Am J Med 2023; 136:814-823.e8. [PMID: 37156347 DOI: 10.1016/j.amjmed.2023.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Previous studies using cardiac troponin levels to investigate the relationship between myocardial injury and mortality in sepsis patients have been conflicting. Our aim was to investigate the relationship between plasma high-sensitive cardiac troponin T (hs-cTnT) level and 30-day and 1-year mortality in sepsis patients and 30- to 365-day mortality in sepsis survivors. METHODS Sepsis patients requiring vasopressor support and admitted to our institution between 2012 and 2021 (n = 586) were included in this retrospective cohort study. Elevated hs-cTnT values (≥15 ng/L) were divided into quartiles (Q): Q1 15-35 ng/L; Q2 36-61 ng/L; Q3 62-125 ng/L; Q4 126-8630 ng/L. Stratified Kaplan-Meier curves and multivariable Cox regression were used for survival analyses. RESULTS First sampled hs-cTnT was elevated in 529 (90%) patients. One-year mortality was 45% (n = 264). Increasing level of hs-cTnT was independently associated with higher adjusted hazard ratios (HR) for 1-year mortality compared with normal levels: Q1 HR 2.9 (95% confidence interval [CI], 1.03-8.1); Q2 HR 3.5 (95% CI, 1.2-9.8); Q3 HR 4.8 (95% CI, 1.7-13.4); Q4 HR 5.7 (95% CI, 2.1-16). In acute phase survivors, first sampled hs-cTnT was an independent predictor of 30- to 365-day mortality (HR 1.3; 95% CI, 1.1-1.6 per loge hs-cTnT). CONCLUSIONS First sampled plasma hs-cTnT in critically ill sepsis patients was independently associated with 30-day and 1-year mortality. Importantly, first sampled hs-cTnT was associated with mortality during the convalescence phase (30- to 365-day) and could be a feasible marker to identify acute phase survivors at high risk of death.
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Affiliation(s)
- Samantha Lörstad
- Division of Internal Medicine and Infectious Diseases, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden.
| | - Shajan Shekarestan
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Sara Tehrani
- Division of Internal Medicine and Infectious Diseases, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Per Åstrand
- Internal Medicine and Infectious Diseases Clinic, Danderyd University Hospital, Stockholm, Sweden
| | - Patrik Gille-Johnson
- Internal Medicine and Infectious Diseases Clinic, Danderyd University Hospital, Stockholm, Sweden
| | - Jonas Persson
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
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Angriman F, Lawler PR, Shah BR, Martin CM, Scales DC. Prevalent diabetes and long-term cardiovascular outcomes in adult sepsis survivors: a population-based cohort study. Crit Care 2023; 27:302. [PMID: 37525272 PMCID: PMC10391991 DOI: 10.1186/s13054-023-04586-4] [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] [Received: 05/12/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Sepsis survivors are at elevated risk for cardiovascular disease during long-term follow-up. Whether diabetes influences cardiovascular risk after sepsis survival remains unknown. We sought to describe the association of diabetes with long-term cardiovascular outcomes in adult sepsis survivors. METHODS Population-based cohort study in the province of Ontario, Canada (2008-2017). Adult survivors of a first sepsis-associated hospitalization, without pre-existing cardiovascular disease, were included. Main exposure was pre-existing diabetes (any type). The primary outcome was the composite of myocardial infarction, stroke, and cardiovascular death. Patients were followed up to 5 years from discharge date until outcome occurrence or end of study period (March 2018). We used propensity score matching (i.e., 1:1 to patients with sepsis but no pre-existing diabetes) to adjust for measured confounding at baseline. Cause-specific Cox proportional hazards models with robust standard errors were used to estimate hazard ratios (HR) alongside 95% confidence intervals (CI). A main secondary analysis evaluated the modification of the association between sepsis and cardiovascular disease by pre-existing diabetes. RESULTS 78,638 patients with pre-existing diabetes who had a sepsis-associated hospitalization were matched to patients hospitalized for sepsis but without diabetes. Mean age of patients was 71 years, and 55% were female. Median duration from diabetes diagnosis was 9.8 years; mean HbA1c was 7.1%. Adult sepsis survivors with pre-existing diabetes experienced a higher hazard of major cardiovascular disease (HR 1.25; 95% CI 1.22-1.29)-including myocardial infarction (HR 1.40; 95% CI 1.34-1.47) and stroke (HR 1.24; 95% CI 1.18-1.29)-during long-term follow-up compared to sepsis survivors without diabetes. Pre-existing diabetes modified the association between sepsis and cardiovascular disease (risk difference: 2.3%; 95% CI 2.0-2.6 and risk difference: 1.8%; 95% CI 1.6-2.0 for the effect of sepsis-compared to no sepsis-among patients with and without diabetes, respectively). CONCLUSIONS Sepsis survivors with pre-existing diabetes experience a higher long-term hazard of major cardiovascular events when compared to sepsis survivors without diabetes. Compared to patients without sepsis, the absolute risk increase of cardiovascular events after sepsis is higher in patients with diabetes (i.e., diabetes intensified the higher cardiovascular risk induced by sepsis).
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Affiliation(s)
- Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Patrick R Lawler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- McGill University Health Centre, Montreal, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Baiju R Shah
- ICES, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Claudio M Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Lawson Health Research Institute, London, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Wardi G, Pearce A, DeMaria A, Malhotra A. Describing Sepsis as a Risk Factor for Cardiovascular Disease. J Am Heart Assoc 2023; 12:e028882. [PMID: 36722383 PMCID: PMC9973636 DOI: 10.1161/jaha.122.028882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Gabriel Wardi
- Department of Emergency MedicineUniversity of California at San DiegoLa JollaCAUSA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal MedicineUniversity of California at San DiegoLa JollaCAUSA
| | - Alex Pearce
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal MedicineUniversity of California at San DiegoLa JollaCAUSA
| | - Anthony DeMaria
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of California at San DiegoLa JollaCAUSA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal MedicineUniversity of California at San DiegoLa JollaCAUSA
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