感染性休克病死率和危险因素分析

目的：回顾性分析感染性休克的病死率和相关危险因素。方法：回顾性分析71例1994年1月～2004年10月源自中山大学附属第二医院的感染性休克患者资料，比较近10年死亡率的变化，对感染性休克的病死危险因素做单因素分析和多因素Logistic回归。结果：1994年～2004年间，感染性休克患者的总死亡率是64．8％．近10年间病死率无明显变化(P=0．725)；合并器官功能衰竭的数目越多，死亡率越高；性别(OR=0．206)、MODS数目(OR=11．387)、SIRS数目(OR=6．335)均是危险因素，其中MODS数目是强危险因素。结论：近10年感染性休克的病死率无明显下降趋势，需注重防治MODS，及早采取各种保护器官功能的支持疗法。     

医院获得性急性肾功能衰竭的病死危险因素分析调查及临床对策

目的调查医院获得性急性肾功能衰竭(肾衰)的病死率及死亡危险因素。方法回顾性调查1991～1996年的1056例危重病患者,利用队列研究方法对医院获得性急性肾衰患者死亡危险因素进行分析。结果1　056例危重病患者中,143例发生急性肾衰,病死率64.34%。患者平均APACHEⅡ评分(24.20±8.53)分,而Liano急性肾衰预后评分(ATNISS)为(72.46±25.58)%。单纯急性肾衰的住院病死率为0,而急性肾衰合并肾外器官衰竭数目越多,患者的病死率越高。合并1个肾外器官衰竭者病死率25.00%,2个肾外器官衰竭者为47.62%,3个肾外器官衰竭者为81.58%,而发生4个肾外器官功能衰竭者病死率达90.20%。22个因素参与急性肾衰死亡危险因素的单因素分析,结果显示年龄(>60岁)、免疫功能低下、APACHEⅡ评分(>20分)、非手术、全身性炎症反应的程度、严重全身性感染、感染性休克、器官衰竭数目、机械通气、昏迷、低血压、黄疸及少尿等因素均与急性肾衰死亡关系显著(P均<0.05)。急性肾衰患者的最常见的直接病死原因是顽固性感染性休克(46.74%)。结论充分认识急性肾衰死亡的危险因素,并积极控制机体炎症反应,防治多器官功能衰竭,可能是降低急性肾衰病死率的关键。     

多器官功能障碍综合征的死亡危险因素分析及临床对策

目的　调查多器官功能障碍综合征 (MODS)的病死率及病死危险因素。方法　回顾性调查 1991至 1996年的 10 5 6例危重病患者 ,利用队列研究方法对MODS病死危险因素进行分析。结果　 10 5 6例危重病患者中 ,339例发生MODS ,病死率 49 3%。 1991～ 1996年 6年期间MODS病死率无明显变化 ,以年龄 ( >6 0 )和APACHEⅡ评分 ( >2 0分 )对病死率进行调整 ,调整率 6年间均无显著变化。 16个因素参与统计学分析 ,结果显示器官衰竭数目、免疫功能低下、转入时的APACHEⅡ评分、非手术、感染性休克等因素与MODS患者的病死关系显著 (P <0 0 5 )。发生 2个器官功能衰竭者病死率 17 8% ,3个器官衰竭者为 47 1% ,4个器官衰竭者为77 0 % ,而发生 5个或 5个以上器官功能衰竭者 ,病死率为 87 9%。结论　 90年代以来MODS病死率依然很高 ,充分认识MODS病死的危险因素 ,并积极调控机体炎症反应 ,防治感染性休克发生 ,可能是降低MODS病死率的关键     

急性呼吸窘迫综合征患者病死危险因素的调查

目的：调查急性呼吸窘迫综合征（ＡＲＤＳ）的病死率及危险因素。方法：回顾性调查北京协和医院ＩＣＵ１９９１年～１９９６年的２１４例ＡＲＤＳ患者，进行单因素和多因素Ｌｏｇｉｓｔｉｃ回归分析。结果：ＡＲＤＳ总病死率为５１．４０％。以年龄（＞６０岁）、性别（男）、ＡＰＡＣＨＥⅡ评分（＞２０分）对病死率进行调整，调整后６年间病死率均无显著变化。多因素分析显示ＡＲＤＳ病死危险因素有：①肺外器官功能衰竭；②免疫功能低下；③慢性疾病史；④感染性休克；⑤ＡＰＡＣＨＥⅡ评分。未发生肺外器官功能衰竭者全部存活，而发生肺外器官功能衰竭者，病死率５７．２９％，衰竭器官数目越多，病死率越高。机械通气支持技术的进步使ＡＲＤＳ患者死于顽固性低氧血症仅１２．７３％；直接死于感染性休克者占４８．１８％。结论：该院９０年代以来ＡＲＤＳ病死率并未下降；防止全身性感染或创伤发展为感染性休克或多器官衰竭是降低ＡＲＤＳ病死率的关键     

多器官功能衰竭综合征的死亡危险因素分析

目的 调查多器官功能衰竭综合征(MODS)的原发病因、病死率及死亡危险因素。方法 回顾性分析413例MODS患者的临床资料。结果 MODS原发病因是重症感染、创伤、重症胰腺炎、休克、心肺复苏后、烧伤、病理产科等。其病死率仍较高，413例MODS患者，病死率为53.5％。本研究的单因素分析显示，合并有慢性疾病者、心电图异常者病死率较高；病死率随着受累器官数目的增加而增高；与存活组比较，死亡组年龄、体温、血糖、血BUN、血肌酐较高，血Ph、GCS分值较低。经Logistic回归分析，既往健康状况、功能衰竭器官数目、GCS分值是主要死亡危险因素，住院时间长是保护性因素。结论 MODS病死率仍较高，既往健康状况、功能衰竭器官数目、GCS分值是主要的死亡危险因素。     

早期目标导向治疗在感染性休克中应用的临床探讨

目的观察“早期目标导向治疗”（EGDT）对感染性休克的临床效果。方法将203例感染性休克患者根据接受治疗的手段分为治疗组（n=98）和对照组（n=105），同时根据治疗开始时患者器官功能的情况，按多器官功能障碍综合征（MODS）评分标准将两组患者进一步分为器官功能轻度受损（A层）、中度受损（B层）和重度受损（C层），分别比较两组患者的病死率及器官衰竭发生率。结果治疗组A、B和C层患者的病死率分别为27．78％（15／54例）、75．86％（22／29例）和93．33％（14／15例），器官衰竭发生率分别为31．48％（17／54例）、55．17％（16／29例）和40．00％（6／15例）；对照组A、B和C层患者的病死率分别为37．50％（18／48例）、76．92％（20／26例）和96．77％（30／31例）。器官衰竭发生率分别为43．75％（21／48例）、57．69％（15／26例）和41．93％（13／31例）。两组患者的病死率和器官衰竭发生率在A层水平上差异均有显著性（P均＜0．05），而在B层和C层水平上差异均无显著性（P均＞0．05）。结论EGDT能显著降低感染性休克早期患者的病死率与器官衰竭发生率，但不能相应改善感染性休克中、晚期患者的生存和预后情况。     

多器官功能障碍综合征合并急性肾功能衰竭患者的病死危险因素分析

目的调查在ICU住院期间多器官功能障碍综合征(MODS)患者出现急性肾功能衰竭(ARF)的病死率及死亡危险因素。方法回顾性调查1998年至2002年住北京六家医院ICU的MODS患者共413例,采用流行病学研究方法对其中合并ARF患者死亡危险因素进行分析。结果413例MODS患者中,135例发生ARF,死亡77例,病死率57.03%。患者入院第一天平均APACHEⅡ评分(17.15±6.67)分。合并1个肾外器官功能衰竭者病死率28.00%,2个肾外器官功能衰竭者为58.62%,3个肾外器官功能衰竭者为61.29%,并发4个肾外器官功能衰竭者病死率达77.78%。单因素分析显示,机械通气、昏迷、低血压、少尿和器官衰竭的数目及血肌酐(Cr)峰值等因素均与ARF死亡关系显著(P<0.05)。对上述死亡危险因素进行Logistic回归分析,结果显示肿瘤术后、昏迷、严重代谢性酸中毒、应用肝素、制酸剂、机械通气等对死亡的影响有显著意义。结论在ICU的MODS患者中,出现ARF的死亡率很高,且与肾外器官衰竭的数目密切相关。     

感染性休克的主要死因—多器官衰竭

30年来我院共收治感染性休克242例,其中160例(66.1%)发生了多器官衰竭,败血症发生率最高,为74.1%,其次为中毒性菌痢、暴发性流脑和休克型肺炎,分别为50%,45.4%和39.3%。累及器官数目与病死率密切相关。无器官衰竭者,无1例死亡。四器官功能衰竭者病死率为86.9%,五器官衰竭者为100%。并结合文献,对感染性休克和多器官衰竭的诊断及治疗进行了讨论。     

休克型猪链球菌II型感染患者的器官功能衰竭和支持治疗对预后的影响

目的观察猪链球菌II型感染导致感染性休克的器官功能衰竭和支持治疗对患者预后的影响.方法以2005年7月至8月在四川省部分地区发生的休克型猪链球菌II感染患者为研究对象,观察器官功能衰竭和治疗情况以及预后.结果 15例休克型猪链球菌II型感染患者均有明确的宰杀或处理病死猪肉的病史,从处理病死猪到发病的时间,即平均潜伏期2.13 d,3例死亡患者的潜伏期均<1 d.入院时80%的患者有严重的全身炎症反应表现,符合SIRS四项指标中(2.4±1.0)项.入院时的急性生理和既往健康评分(APACHE) II 为(12.9±5.9).所有患者均给予积极的抗感染治疗和器官功能支持治疗.15例患者死亡3例,病死率为20%.存活组和死亡组的APACHE II、多器官功能障碍综合征(MODS)评分、感染相关的器官衰竭评分(SOFA)和简化性急性生理评分(SAPS) II均无显著差异.15例患者13例发生MODS(86.7%),平均器官衰竭数为(3.1±1.5)个.所有患者均有循环衰竭,其次依次是呼吸(60.0%)、血液(53.3%)、肾脏(40.0%)、肝脏(33.3%)、中枢神经系统功能衰竭(25.0%).顽固性感染性休克为最常见的直接病死原因.结论休克型猪链球菌II感染发病急骤,并迅速出现MODS,病死率高,早期实施强有力的抗感染和器官功能支持治疗,能够明显降低休克型患者的病死率.     

老年肺炎合并感染性休克患者预后相关因素分析

目的 探讨老年肺炎合并感染性休克患者预后相关因素.方法 分析88例老年肺炎合并感染性休克患者的临床资料,用单因素分析比较不同预后组患者预后可能相关因素,再将有统计学差异的因素用多因素回归分析筛选出与死亡相关的独立危险因素.结果 老年肺炎合并感染性休克患者病死率56.8％,单因素分析结果提示死亡组年龄、APACHEⅡ评分、功能不全脏器的数量、干预前及治疗6h后血乳酸水平均显著高于存活组（均P ＜0.05）,且神经、凝血、肾功能不全的发生率均高于存活组（均P＜0.05）,多因素Logistic分析提示入ICU时APACHEⅡ评分≥26.5分、治疗6h后血乳酸水平≥4.0 mmol/L、器官衰竭数量≥3.6个、神经功能不全为不良预后的独立危险因素.结论 老年肺炎患者一旦合并感染性休克病死率就会高,其治疗前病情危重程度、早期干预后血乳酸水平、脏器功能不全的数量（尤其是脑）与预后密切相关,因此如何尽早干预以降低血乳酸水平、避免脏器功能受损对患者预后有极其重要的意义.     

Rifle classification for predicting in-hospital mortality in critically ill sepsis patients

Severe sepsis and septic shock, often complicated by acute kidney injury (AKI), are the most common causes of mortality in noncoronary intensive care units (ICUs). This study investigates the outcomes of critically ill patients with sepsis and elucidates the association between prognosis and risk of renal failure, injury to the kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification. A total of 121 sepsis patients were admitted to ICU from June 2003 to January 2004. Forty-seven demographic, clinical, and laboratory variables were prospectively recorded for post hoc analysis as predictors of survival on the first day of ICU admission. Overall in-hospital mortality rate was 47.9%. Mortality was significantly associated (chi-square for trend; P < 0.001) with RIFLE classification. Septic shock, RIFLE category, and number of organ system failures on the first day of ICU admission were independent predictors of hospital mortality according to forward conditional logistic regression. The severity of RIFLE classification correlated with organ system failure number and Acute Physiology and Chronic Health Evaluation (APACHE) II to IV and sequential organ failure assessment scores. Cumulative survival rates at 6-month follow-up after hospital discharge significantly (P < 0.05) differed between non-AKI versus RIFLE injury, non-AKI versus RIFLE failure (RIFLE-F), and RIFLE risk versus RIFLE F. At 6-month follow-up, full recovery of renal function was noted in 85% of surviving patients with AKI (RIFLE risk, RIFLE injury, and RIFLE-F). In conclusion, these findings are consistent with a role for RIFLE classification in accurately predicting in-hospital mortality and short-term prognosis in ICU sepsis patients.     

Effect of critical illness polyneuropathy on the withdrawal from mechanical ventilation and the length of stay in septic patients

OBJECTIVES: No previous study has demonstrated whether critical illness polyneuropathy itself lengthens mechanical ventilation or whether this prolonged duration of ventilatory support is explained by concomitant risk factors for weaning failure. Our objectives were to evaluate the impact of critical illness polyneuropathy on the length of mechanical ventilation after controlling for coexisting risk factors for weaning failure and to assess the impact of critical illness polyneuropathy on the length of the stay in a cohort of septic patients. DESIGN: Prospective cohort study. SETTING: Intensive care unit of a tertiary hospital. PATIENTS: All patients with severe sepsis or septic shock who required mechanical ventilation for > or =7 days who were considered ready to discontinue mechanical ventilation. INTERVENTIONS: Patients underwent a neurophysiologic evaluation at onset of weaning from mechanical ventilation. MEASUREMENTS AND MAIN RESULTS: Sixty-four critically ill septic patients were enrolled, and 34 developed critical illness polyneuropathy (53.1%; 95% confidence interval, 40.2-65.7%). Length of mechanical ventilation was significantly higher in patients who had developed critical illness polyneuropathy (median 34 days vs. 14 days, p < .001). The duration of the weaning period was also significantly greater in patients with critical illness polyneuropathy (median 15 days vs. 2 days, p < .001) even though factors suspected to influence the weaning process did not differ between these two groups. Multiple logistic regression analysis indicated that critical illness polyneuropathy was the only risk factor independently associated with weaning failure (odds ratio, 15.4; 95% confidence interval, 4.55, 52.3; p < .001). Lengths of intensive care unit and hospital stays were significantly higher in patients with critical illness polyneuropathy. CONCLUSIONS: In critically ill septic patients, critical illness polyneuropathy significantly increases the duration of mechanical ventilation and prolongs the lengths of intensive care unit and hospital stays.     

Sepsis in patients with intracranial hemorrhage: incidence and influence on outcome

The aim of the study is to analyze sepsis and septic shock incidence and their influence on the outcome in critically ill patients with intracranial hemorrhage. Sepsis incidence (33,7%) and septic shock incidence (18,6%) in the patients studied did not depend on intracranial hemorrhage etiology. Septic complications led to higher mortality which was 22,8% in patients with sepsis and 74,4% in patients with septic shock. Sepsis and septic shock risk factors are defined. The problem of sepsis and septic shock diagnosis in critically ill patients with intracranial hemorrhage are highlighted.     

Ischemic skin lesions as a complication of continuous vasopressin infusion in catecholamine-resistant vasodilatory shock: incidence and risk factors

OBJECTIVE: To report on the incidence and risk factors associated with the development of ischemic skin lesions (ISL) in critically ill patients with catecholamine-resistant vasodilatory shock treated with a continuous infusion of arginine-vasopressin (AVP). DESIGN: Retrospective analysis. SETTING: Twelve-bed general and surgical intensive care unit in a university hospital. PATIENTS: A total of 63 critically ill patients with catecholamine-resistant vasodilatory shock. INTERVENTIONS: Continuous AVP infusion. MEASUREMENTS AND MAIN RESULTS: Demographic, hemodynamic, laboratory data, and skin status were evaluated 24 hrs before and during AVP therapy (24 and 48 hrs). Patients were grouped according to development of new ISL during AVP therapy. A mixed-effects model was used to compare groups. A multiple logistic regression analysis was used to identify independent risk factors for the development of ISL. ISL developed in 19 of 63 patients (30.2%). Thirteen of 19 patients (68%) developed ISL in distal limbs, two patients (10.5%) developed ISL of the trunk, four patients (21%) developed ISL in distal limbs and in the trunk. Five patients (26%) had additional ischemia of the tongue. Body mass index, preexistent peripheral arterial occlusive disease, presence of septic shock, and norepinephrine requirements were significantly higher in patients developing ISL. ISL patients received significantly more units of fresh frozen plasma and thrombocyte concentrates than patients without ISL. Preexistent peripheral arterial occlusive disease and presence of septic shock were independently associated with the development of ISL during AVP therapy. CONCLUSIONS: ISLs are a common complication during continuous AVP infusion in patients with catecholamine-resistant vasodilatory shock. The presence of septic shock and a history of peripheral arterial occlusive disease are independent risk factors for the development of ISL.     

A multicenter study of septic shock due to candidemia: outcomes and predictors of mortality

Purpose

Candida is the most common cause of severe yeast infections worldwide, especially in critically ill patients. In this setting, septic shock attributable to Candida is characterized by high mortality rates. The aim of this multicenter study was to investigate the determinants of outcome in critically ill patients with septic shock due to candidemia.

Methods

This was a retrospective study in which patients with septic shock attributable to Candida who were treated during the 3-year study period at one or more of the five participating teaching hospitals in Italy and Spain were eligible for enrolment. Patient characteristics, infection-related variables, and therapy-related features were reviewed. Multiple logistic regression analysis was performed to identify the risk factors significantly associated with 30-day mortality.

Results

A total of 216 patients (mean age 63.4 ± 18.5 years; 58.3 % males) were included in the study. Of these, 163 (75 %) were admitted to the intensive care unit. Overall 30-day mortality was 54 %. Significantly higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, dysfunctional organs, and inadequate antifungal therapy were compared in nonsurvivors and survivors. No differences in survivors versus nonsurvivors were found in terms of the time from positive blood culture to initiation of adequate antifungal therapy. Multivariate logistic regression identified inadequate source control, inadequate antifungal therapy, and 1-point increments in the APACHE II score as independent variables associated with a higher 30-day mortality rate.     

液体过负荷对脓毒症相关性AKI接受CRRT患者主要肾脏不良事件的影响

目的探讨液体过负荷（FO）对脓毒症相关性急性肾损伤（septic AKI）接受持续性肾替代治疗（CRRT）患者主要肾脏不良事件（MAKE）的影响。 方法对首都医科大学附属北京友谊医院重症医学科2015年1月至2019年6月收治的septic AKI接受CRRT的223例患者的临床资料进行回顾性分析,根据患者FO分为2组（FO＞5%和FO≤5%）,收集CRRT启动时患者的人口学特征,肌酐基线值,临床基本资料,合并症,实验室数据,ICU到CRRT时间,CRRT启动前24 h内尿量以及疾病严重程度评估,入院到CRRT启动时累计液体平衡。应用logistic回归分析观察FO是否是此类患者发生MAKE的独立危险因素。 结果223例接受CRRT的脓毒性AKI患者的MAKE发生率为72.1%;FO＞5%的患者28 d MAKE发生率明显高于FO≤5%的患者,差异有统计学意义（88.3% vs 60.2%,P＜0.001）。调整混杂因素的二元logistic回归显示FO＞5%的患者与发生MAKE风险独立相关（OR=4.680,95%CI：1.990~11.006,P＜0.001）。 结论在接受CRRT的septic AKI危重患者中,FO＞5%与MAKE风险增加独立相关。     

Septic shock and multiple organ failure

OBJECTIVE: To assess the frequency and mortality rates of septic shock in ICU patients and the clinical course of multiple organ failure associated with septic shock. DESIGN: Retrospective case survey. SETTING: Tertiary care center. PATIENTS: During a 2-yr period, 2,469 consecutive intensive care patients were studied regarding the frequency and hospital mortality rates of septic shock. A subset of 1,311 patients was further analyzed for the occurrence of organ system failures within 48 hrs of the onset of septic shock and again 4 to 7 days later. MEASUREMENTS AND MAIN RESULTS: The frequency rate of septic shock was 1.9% (n = 48), with a mortality rate of 72.9% (n = 35) in patients with septic shock. Deaths due to septic shock represented 14.6% of all deaths in the ICU during the study period. Eighteen patients died within 72 hrs of the onset of septic shock. Refractory hypotension was the cause of death in 15 of these 18 patients. Beyond 72 hrs, multiple organ failure accounted for eight of 17 deaths. The mean +/- SD number of organ systems failing at 48 hrs was 3.3 +/- 1.3 in survivors and 4.0 +/- 1.1 in nonsurvivors, and at 4 to 7 days was 2.1 +/- 1.5 in survivors and 4.0 +/- 1.5 in nonsurvivors (p less than .05). None of the specific organ system failures had prognostic value. The number of organ system failures was not related to the duration of hypotension, but had a weak correlation (r2 = .26, p less than .05) with the duration of vasoactive treatment at 4 to 7 days. The prolonged need for norepinephrine therapy was associated with an increased occurrence of renal failure. Thirty (62.5%) patients had positive blood cultures and a mortality rate similar to the mortality rate of patients with negative blood cultures. Patients with negative blood cultures died more often with hypotension (p less than .02). CONCLUSIONS: Septic shock is a major cause of death in intensive care patients. Refractory hypotension is a main cause of early deaths. Later on, multiple organ failure becomes the primary clinical problem and cause of mortality.     

Development of septic shock and prognostic assessment in critically ill patients with coronavirus disease outside Wuhan,China

BACKGROUND: The study aims to illustrate the clinical characteristics and development of septic shock in intensive care unit (ICU) patients confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and to perform a comprehensive analysis of the association between septic shock and clinical outcomes in critically ill patients with coronavirus disease (COVID-19). METHODS: Patients confirmed with SARS-CoV-2 infection, who were admitted to the ICU of the Third People’s Hospital of Shenzhen from January 1 to February 7, 2020, were enrolled. Clinical characteristics and outcomes were compared between patients with and without septic shock. RESULTS: In this study, 35 critically ill patients with COVID-19 were included. Among them, the median age was 64 years (interquartile range [IQR] 59-67 years), and 10 (28.4%) patients were female. The median ICU length of stay was 16 days (IQR 8-23 days). Three (8.6%) patients died during hospitalization. Nine (25.7%) patients developed septic shock in the ICU, and these patients had a significantly higher incidence of organ dysfunction and a worse prognosis than patients without septic shock. CONCLUSIONS: Septic shock is associated with a poor outcome in critically ill COVID-19 patients and is one of the hallmarks of the severity of patients receiving ICU care. A dysregulated immune response, uncontrolled inflammation, and coagulation disorders are strongly associated with the development and progression of COVID-19-related septic shock.