Analysis of prognostic factors in patients with sepsis and septic shock in intensive care unit北大核心CSCD

Objective To investigate the risk factors of death in patients with sepsis and septic shock and analyze the prognostic factors of patients in ICU. Methods A total of 168 patients with sepsis and septic shock in ICU from June 2016 to October 2018 were enrolled. The patients were stratified in terms of survival time (60 days or not). General clinical data, length of hospital stay, APACHE II score, underlying diseases, and laboratory data were used to analyze the independent risk factors of patient mortality. Results Of the 168 patients enrolled, 66 (39.3%) died within 60 days of discharge and 102 survived. Survivor and non-survivor groups did not show significant difference in gender, age, and length of hospital stay. APACHE II score in the non-survivor group was significantly higher than survivor group (P＜0.05). Considering the underlying diseases in the non-survivor group and survivor group, chronic obstructive pulmonary disease was found in 44 and 56 cases;hypertension in 63 and 69 cases;chronic liver disease in 34 and 30 cases;tumor in 21 and 18 cases, respectively (P＜0.05). The prevalence of coronary atherosclerotic heart disease, chronic renal insufficiency, diabetes mellitus, and stroke did not show significant difference between the two groups. The patients in both survivor group and non-survivor group did not show significant difference in C-reactive protein, white blood cell count, oxygenation index, blood lactate, serum creatinine, and platelet count within 36 hours in ICU. After 37-48 hours of treatment, C-reactive protein level was significantly higher in survivor group than non-survivor group (P＜0.05). Conclusion Underlying chronic obstructive pulmonary disease, tumor, hypertension, chronic liver disease, high C-reactive protein level after treatment for 37-48 hours, and high APACHE II score are independent risk factors for death of septic patients in ICU. © 2019, Editorial Department of Chinese Journal of Infection. All rights reserved.     

Impact of secondary sepsis on mortality in adult intensive care unit patients

RationaleSeptic patients admitted to the intensive care unit (ICU) suffer from immune dysregulation, potentially leading to a secondary sepsis episode. This study aims to (i) assess the secondary sepsis rate, (ii) compare the second with the first episodes in terms of demographics, clinical and laboratory characteristics, and outcomes, and iii) evaluate the outcome of secondary sepsis.MethodsA single-center, retrospective study (2014–2017) was conducted in a Greek ICU, including consecutive cases of adult patients admitted to the ICU for at least 48 h with a principal admission diagnosis of sepsis and stayed for at least 48 h. We searched for a secondary episode of sepsis following the primary-one. We performed survival analyses with Cox proportional hazard, Fine-Gray, and multistate models.ResultsIn this study, 121 patients that fulfilled the eligibility criteria were included. The secondary sepsis group included 28 (23.1 %) patients, with episode onset, median (interquartile range), 9.5 (7.7–16.2) days after ICU admission, who had less frequently had a medical admission diagnosis, a microbiologically confirmed first episode, and the C-reactive protein was lower. The overall ICU mortality of the cohort was 44.6 %. The group that developed secondary sepsis had higher mortality, but significance was lost in Cox regression [Hazard ratio (95 % CI) 0.59(0.31–1.16)]. However, after multistate modeling adjustment, the attributable mortality was estimated at 43.9 % (95 %CI ± 14.8 %).ConclusionSecondary sepsis was evident in a quarter of the study participants and may be associated with an increased risk of death.     

Long-term costs and cost-effectiveness of adjunctive corticosteroids for patients with septic shock in New Zealand

ObjectiveThe aim of the study was to determine whether adjunctive hydrocortisone reduced healthcare expenditure and was cost-effective compared with placebo in New Zealand patients in the Adjunctive Glucocorticoid Therapy in Patients with Septic Shock (ADRENAL) trial.DesignThis is a health economic analysis using data linkage to New Zealand Ministry of Health databases to determine resource use, costs, and cost-effectiveness for a 24-month period.SettingThe study was conducted in New Zealand.Participants and interventionPatients with septic shock were randomised to receive a 7-day continuous infusion of 200 mg of hydrocortisone or placebo in the ADRENAL trial.Main outcome measuresHealthcare expenditure was associated with all hospital admissions, emergency department presentations, outpatient visits, and pharmacy expenditure. Effectiveness outcomes included mortality at 6 months and 24 months and quality of life at 6 months. Cost-effectiveness outcomes were assessed with reference to quality-adjusted life years gained at 6 months and life years gained at 24 months.ResultsOf 3800 patients in the ADRENAL trial, 419 (11.0%) were eligible, and 405 (96.7% of those eligible) were included. The mean total costs per patient over 24 months were $143,627 ± 100,890 and $143,772 ± 97,117 for the hydrocortisone and placebo groups, respectively (p = 0.99). Intensive care unit costs for the index admission were $50,492 and $62,288 per patient for the hydrocortisone and placebo groups, respectively (p = 0.09). The mean number of quality-adjusted life years gained at 6 months and mean number of life years gained at 24 months was not significantly different by treatment group, and the probability of hydrocortisone being cost-effective was 55% at 24 months.ConclusionsIn New Zealand, adjunctive hydrocortisone did not reduce total healthcare expenditure or improve outcomes compared with placebo in patients with septic shock.     

The influence of esmolol on septic shock and sepsis: A meta-analysis of randomized controlled studies

Background

Esmolol may have some potential in treating septic shock and sepsis. However, the results remain controversial. We conduct a systematic review and meta-analysis to explore the efficacy of esmolol in patients with septic shock and sepsis.

Neopterin as a prognostic biomarker in intensive care unit patients

Purpose

The present study was undertaken to evaluate urinary neopterin in intensive care unit patients.

Materials and Methods

Urinary neopterin levels were determined in systemic inflammatory response syndrome (n = 10), sepsis (n = 18), septic shock (n = 9), and multiple organ dysfunction syndrome (n = 5). It was tested whether neopterin is a differential parameter among the patient groups. Furthermore, the results were also evaluated by comparing with a healthy control group (n = 30), and the relationship between neopterin and mortality or Acute Physiology and Chronic Health Evaluation II scores were investigated.

Results

Neopterin levels of the control group and patients were detected as 111 ± 11 and 3850 ± 1081 μmol/mol creatinine, respectively (P < .05). It was significantly increased in the sepsis and septic shock groups compared to the systemic inflammatory response syndrome group (P < .05). Neopterin levels were significantly higher in the patients with mortality and lower Acute Physiology and Chronic Health Evaluation II scores.

Conclusion

This study showed that monitoring of urinary neopterin profile can be used in intensive care units to show the degree and prognosis of the disease.     

The clinical course of patients with septic abortion admitted to an intensive care unit

Objective The purpose of this study was to describe the clinical course, complications, and outcome of patients with septic abortion admitted to the intensive care unit (ICU).Design, setting, and patients In this retrospective study, the records of 63 patients with septic abortion admitted to the ICU of a university hospital in Argentina between 1985 and 1995 were reviewed.Results The mean age of the patients was 28.5 years, and 33% had had previous abortions. The mean gestational age was 10.5 weeks. The first ICU day Acute Physiology and Chronic Health Evaluation (APACHE) II mean score was 13.9. Acute renal failure developed in 73% (46 of 63) of the patients, disseminated intravascular coagulation (DIC) in 31% (15 of 49), and septic shock in 32% (20 of 63). Blood cultures were positive in 24% (15 of 62). Twelve patients died (19%). Eight of the deaths occurred during the first 48 h of the ICU admission. Compared with survivors, non-survivors had higher median number of organ failures (1.0 vs 4.0, p<0.0001), mean first ICU day SOFA scores (6.6 vs 10.0, p=0.0059), and mean APACHE II scores (12.7 vs 20.2, p=0.0003), and were more likely to have septic shock (18 vs 92%, p<0.0001), and receive dopamine (37 vs 83%, p=0.0040), mechanical ventilation (8 vs 83%, p<0.0001), and pulmonary artery catheter (8 vs 41%, p=0.0026).Conclusions Although it is an avoidable complication, septic abortion requiring admission to the ICU is associated with high morbidity and mortality.     

Clinical and economic impact of procalcitonin to shorten antimicrobial therapy in septic patients with proven bacterial infection in an intensive care setting

Biomarkers such as procalcitonin (PCT) have been studied to guide duration of antibiotic therapy. We aimed to assess whether a decrease in PCT levels could be used to reduce the duration of antibiotic therapy in intensive care unit (ICU) patients with a proven infection without risking a worse outcome. We assessed 265 patients with suspected sepsis, severe sepsis, or septic shock in our ICU. Of those, we randomized 81 patients with a proven bacterial infection into 2 groups: an intervention group in which the duration of the antibiotic therapy was guided by a PCT protocol and a control group in which there was no PCT guidance. In the per-protocol analysis, the median antibiotic duration was 9 days in the PCT group (n = 20) versus 13 days in the non-PCT group (n = 31), P = 0.008. This study demonstrates that PCT can be a useful tool for limiting antimicrobial therapy in ICU patients with documented bacterial infection.     

The management of septic abortion in an intensive care unit

The value of ICU treatment in the management of septic abortion has been assessed. Of patients subjected to hysterectomy, the mortality is now 20%, as opposed to 37% prior to the advent of ICU. It would therefore appear that these patients can benefit from intensive nursing and medical attention.     

N末端前B型利钠肽对严重感染及感染性休克患者预后的预测作用

目的 评价N末端前B型利钠肽(NT-proBNP)对严重感染及感染性休克患者预后的预测作用.方法 采用前瞻性研究方法,收集并观察50例严重感染及感染性休克患者的临床资料.于入重症监护病房(ICU)0、24、48、72 h测定血浆NT-proBNP水平,根据住院30 d死亡情况分为死亡组与存活组并进行比较.用受试者工作特征曲线(ROC曲线)评价血浆NT-proBNP水平对死亡的预测作用;采用线性回归分析评价血浆NT-proBNP的干扰因素.结果 死亡组(20例)血浆NT-proBNP水平(μg/L)在入ICU 0 h[20.86(14.28,23.92)]时明显高于存活组[30例,10.02(5.58,16.41),P＜0.01],且这种差异持续至72 h[19.68(13.90,24.02)比9.24(4.30,11.81),P＜0.01],但组内各时间点之间比较均无明显差异;ROC曲线下面积(AUC)为0.842,95%可信区间(95%CI)为0.764～0.922,P＜0.01.以入ICU时血浆NT-proBNP水平＞13.30μg/L作为判断死亡的最佳临界值,其敏感性为80.6%,特异性为70.2%.线性回归分析发现,氧合指数(PaO2/FiO2,r=-0.839,P=0.003)、血小板计数(PLT,r=-0.803,P=0.032)和入ICU 0 h时感染相关器官功能衰竭评分(SOFA,r=0.874,P＜0.001)是NT-proBNP的独立相关因素.结论 血浆NT-proBNP水平可以预测严重感染及感染性休克患者的预后.     

Variation in the care of septic shock: the impact of patient and hospital characteristics

Purpose

The aim of this study was to examine treatments of septic shock in a sample of US hospitals and to assess whether patient and hospital characteristics are associated with use of sepsis therapies.

Materials and Methods

We studied 192 hospitals that treated 50 or more adults with septic shock between 2004 and 2006. We examined hospital-level variation in commonly used therapies including mechanical ventilation, activated protein C (APC), hydrocortisone, central venous pressure (CVP) monitoring, albumin/colloid, and pulmonary artery catheters. We calculated interquartile range to assess the hospital-level variation in treatment. We developed hierarchical mixed-effects logistic regression models to examine the association between patient and hospital characteristics and selected treatments.

Results

A total of 22?702 patients met the inclusion criteria. When compared with patients younger than 45 years, patients 75 years or older were as likely to receive mechanical ventilation but less likely to receive APC (odds ratio [OR], 0.35 [95% confidence interval, 0.27-0.45]), hydrocortisone (OR, 0.65 [0.56-0.75]), or CVP monitoring (OR, 0.73 [0.63-0.84]). Compared with whites, black patients were more likely to be mechanically ventilated (OR, 1.15 [1.05-1.25]) but less likely to receive hydrocortisone (OR, 0.86 [0.78-0.95]) or APC (0.70 [0.58-0.86]).

Conclusion

Treatment of septic shock varies across hospitals. In contrast to mechanical ventilation, treatments with weaker supporting evidence showed greater variation, especially among black and older patients.     

Optimizing antimicrobial therapy in sepsis and septic shock

Every patient with sepsis and septic shock must be evaluated thoroughly at presentation before the initiation of antibiotic therapy. However, in most situations, an abridged initial assessment focusing on critical diagnostic and management planning elements is sufficient. Intravenous antibiotics should be administered as early as possible, and always within the first hour of recognizing severe sepsis and septic shock. Broad-spectrum antibiotics must be selected with one or more agents active against likely bacterial or fungal pathogens and with good penetration into the presumed source. Antimicrobial therapy should be reevaluated daily to optimize efficacy, prevent resistance, avoid toxicity, and minimize costs. Consider combination therapy in Pseudomonas infections, and combination empiric therapy in neutropenic patients. Combination therapy should be continued for no more than 3 to 5 days and de-escalation should occur following availability of susceptibilities. The duration of antibiotic therapy typically is limited to 7 to 10 days; longer duration is considered if response is slow, if there is inadequate surgical source control, or in the case of immunologic deficiencies. Antimicrobial therapy should be stopped if infection is not considered the etiologic factor for a shock state.     

Implementation of the Surviving Sepsis Campaign guidelines for severe sepsis and septic shock: We could go faster

Purpose

The aim of this study is to evaluate the feasibility of applying sepsis bundles in the intensive care unit (ICU) and their effect on outcomes.

Methods

In this prospective, observational study in a 31-bed capacity department of intensive care, we measured the time taken to perform sepsis bundle interventions in 69 consecutive patients with severe sepsis or septic shock.

Results

Compliance with the 6-hour bundle was obtained in 44 (72%) of 61 patients; these patients had a lower mortality rate (16% vs 41%, P = .04) and shorter ICU stay (median [range], 5 [3-10] vs 9 [6-19] days, P = .01) than other patients. Compliance with the 24-hour bundle was obtained in 30 (67%) of 44 eligible patients. The mortality rate and duration of ICU stay were not significantly lower in the 24-hour compliant as compared with the noncompliant group (23% vs 33% and 6 [4-11] vs 9 [6-25] days, respectively; P value is not significant). Patients who complied with the 24-hour sepsis bundle after only 12 hours had a lower mortality rate (10% vs 39%, P = .036) and shorter stay (6 [4-10] vs 9 [6-25] days, P = .055) than those who were compliant after 24 hours.

Conclusions

Correct application of the sepsis bundles was associated with reduced mortality and length of ICU stay. Earlier implementation of the 24-hour management bundle could result in better outcomes.     

Impact of serial measurements of lysophosphatidylcholine on 28-day mortality prediction in patients admitted to the intensive care unit with severe sepsis or septic shock

Purpose

The purpose of this study is to investigate the effect of serial lysophosphatidylcholine (LPC) measurement on 28-day mortality prediction in patients with severe sepsis or septic shock admitted to the medical intensive care unit (ICU).

Methods

This is a prospective observational study of 74 ICU patients in a tertiary hospital. Serum LPC, white blood cell, C-reactive protein, and procalcitonin (PCT) levels were measured at baseline (day 1 of enrollment) and day 7. The LPC concentrations were compared with inflammatory markers using their absolute levels and relative changes.

Results

The LPC concentration on day 7 was significantly lower in nonsurvivors than in survivors (68.45 ± 42.36 μmol/L and 99.76 ± 73.65 μmol/L; P = .04). A decreased LPC concentration on day 7 to its baseline as well as a sustained high concentration of PCT on day 7 at more than 50% of its baseline value was useful for predicting the 28-day mortality. Prognostic utility was substantially improved when combined LPC and PCT criteria were applied to 28-day mortality outcome predictions. Furthermore, LPC concentrations increased over time in patients with appropriate antibiotics but not in those with inappropriate antibiotics.

Conclusions

Serial measurements of LPC help in the prediction of 28-day mortality in ICU patients with severe sepsis or septic shock.     

Toward less sedation in the intensive care unit: a prospective observational study

Purpose

Excessive sedation is associated with prolonged mechanical ventilation and longer intensive care unit (ICU) and hospital stays. We evaluated the feasibility of using minimal sedation in the ICU.

Methods

Prospective observational study in a university hospital 34-bed medico-surgical department of intensive care. All adult patients who stayed in the ICU for more than 12 hours over a 2-month period were included. Intensive care unit admission diagnoses, severity scores, use of sedatives and/or opiates, duration of mechanical ventilation, length of ICU stay, and 28-day mortality were recorded for each patient.

Results

Of the 335 patients (median age, 61 years) admitted during the study period, 142 (42%) received some sedation, most commonly with midazolam and propofol. Sedative agents were administered predominantly for short periods of time (only 10% of patients received sedation for >24 hours). One hundred fifty-five patients (46%) received mechanical ventilation, generating 15?240 hours of mechanical ventilation, of these, only 2993 (20%) hours were accompanied by a continuous sedative infusion. Self-extubation occurred in 6 patients, but only 1 needed reintubation.

Conclusions

In a mixed medical-surgical ICU, minimal use of continuous sedation seems feasible without apparent adverse effects.     

强化康复单元医院获得性肺炎的影响因素分析

目的:分析强化康复单元重症患者发生医院获得性肺炎的影响因素,指导肺炎防控措施的选择。方法:回顾性分析2015年10月—2016年10月在强化康复单元住院治疗的患者108例,根据前4周内是否发生医院获得性肺炎,分为肺炎组和非肺炎组。所有患者收集其一般情况、基础疾病、实验室检查及辅助检查结果、医疗干预措施等相关临床资料,并记录干预措施的累计持续时间。结果:共有59例患者发生医院获得性肺炎。单因素分析显示,肺炎组与非肺炎组之间血清白蛋白水平(t=-5.006,P=0.000)、意识水平(χ2=6.584,P=0.010)、使用声门下吸引功能的气管套管(χ2=6.438,P=0.011)、鼻饲管(P=0.045)、膨肺+振动排痰(χ2=7.521,P=0.006)的差异有显著性意义。二分类非条件Logistic回归分析显示,意识水平高(OR=0.222, 95%CI 0.065—0.757, P=0.016)、膨肺+振动排痰(OR=0.263, 95%CI 0.100—0.689, P=0.007)和血清白蛋白水平高(OR=0.776, 95%CI 0.684—0.879, P=0.000)是强化康复单元医院获得性肺炎的保护因素。结论:意识水平高、膨肺+振动排痰和血清白蛋白水平高是强化康复单元医院获得性肺炎的保护因素,而使用声门下吸引功能的气管套管、鼻饲管亦对其的发生有一定影响,可在临床上采取有针对性的干预措施,降低医院获得性肺炎的发生率。     

Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock

Objective To develop management guidelines for severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.Design The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. The modified Delphi methodology used for grading recommendations built upon a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along 5 levels to create recommendation grades from A–E, with A being the highest grade. Pediatric considerations were provided to contrast adult and pediatric management.Participants Participants included 44 critical care and infectious disease experts representing 11 international organizations.Results A total of 46 recommendations plus pediatric management considerations.Conclusions Evidence-based recommendations can be made regarding many aspects of the acute management of sepsis and septic shock that will hopefully translate into improved outcomes for the critically ill patient. The impact of these guidelines will be formally tested and guidelines updated annually, and even more rapidly when some important new knowledge becomes available.Electronic Supplementary Material Supplementary material is available in the online version of this articel at This article is published jointly with Critical Care MedicineChairs: R. Phillip Dellinger, MD*; Henry Masur, MD; Jean M. Carlet, MD; Herwig Gerlach, MD, PhD**. Committee members: Richard J. Beale, MD**; Marc Bonten, MD; Christian Brun-Buisson, MD; Thierry Calandra, MD; Joseph A. Carcillo, MD; Jonathan Cohen, MD**; Catherine Cordonnier, MD; E. Patchen Dellinger, MD; Jean-Francois Dhainaut, MD, PhD; Roger G. Finch, MD; Simon Finfer, MD; Francois A. Fourrier, MD; Juan Gea-Banacloche MD; Maurene A. Harvey, RN, MPH**; Jan A. Hazelzet, MD; Steven M. Hollenberg, MD; James H. Jorgensen, PhD; Didier Keh, MD; Mitchell M. Levy*, MD; Ronald V. Maier, MD; Dennis G. Maki, MD; John J. Marini, MD; John C. Marshall, MD; Steven M. Opal, MD; Tiffany M. Osborn, MD; Margaret M. Parker, MD**; Joseph E. Parrillo, MD; Graham Ramsay, MD*; Andrew Rhodes, MD; Jonathan E. Sevransky, MD; Charles L. Sprung, MD, JD**; Antoni Torres, MD; Jeffery S. Vender, MD; Jean-Louis Vincent, MD, PhD**; Janice L. Zimmerman, MD. Associate members: E. David Bennett, MD; Pierre-Yves Bochud, MD; Alain Cariou, MD; Glenn S. Murphy, MD; Martin Nitsun, MD; Joseph W. Szokol, MD; Stephen Trzeciak, MD; Christophe Vinsonneau, MD. *Executive Committee, Surviving Sepsis Campaign. **Steering Committee, Surviving Sepsis Campaign.Sponsoring organizations: American Association of Critical-Care Nurses; American College of Chest Physicians; American College of Emergency Physicians; American Thoracic Society; Australian and New Zealand Intensive Care Society; European Society of Clinical Microbiology and Infectious Diseases; European Society of Intensive Care Medicine; European Respiratory Society; International Sepsis Forum; Society of Critical Care Medicine; Surgical Infection Society.The Surviving Sepsis Campaign is administered jointly by the European Society of Intensive Care Medicine, International Sepsis Forum, and the Society of Critical Care Medicine, and is supported in part by unrestricted educational grants from Baxter Bioscience, Edwards Lifesciences, and Eli Lilly and Company (majority sponsor).The authors and the publisher have exercised great care to ensure that drug dosages, formulas, and other information presented in this book are accurate and in accord with the professional standards in effect at the time of publication. Readers are, however, advised to always check the manufacturers product information sheet that is packaged with the respective products to be fully informed of changes in recommended dosages, contraindications, and the like before prescribing or administering any drug.     

Absolute eosinophils count as a marker of mortality in patients with severe sepsis and septic shock in an intensive care unit

Introduction

Eosinophils in the circulating blood undergo apoptosis during sepsis syndromes induced by the action of certain cytokines.

Objective

The aim of the study was to evaluate the absolute eosinophils count (EC) as a marker of mortality in severe sepsis and septic shock.

Patients and Method

A prospective cohort study of patients with a diagnosis of sepsis or septic shock admitted to the intensive care unit (ICU) of the Dr Gustavo Fricke Hospital between January 2008 and December 2009 was conducted. Daily EC in all patients was analyzed. Receiver operating characteristic curve analysis was used to assess the performance of the diagnostic test.

Results

We studied a total of 240 patients. The median age was 62 years (interquartile range [IQR], 48-72 years), and 67 (27.9%) died. The median EC in patients who died was 43 (IQR, 14-121), whereas in surviving patients, it was 168 (IQR, 98-292) (P < .001). When the EC on the fifth day of hospital stay was assessed, an area under the curve (AUC) of 0.64 (95% confidence interval, 0.55-0.73) was observed. Eosinophils count at intensive care unit discharge showed an area under the curve of 0.81 (95% confidence interval, 0.76-0.87).

Discussion

Eosinophils counts were lower in patients who died of sepsis than in those who survived, but its clinical usefulness seems limited. Their role as an indicator of clinical stability seems to be important.