The index of oxygenation to respiratory rate as a prognostic factor for mortality in Sepsis

ObjectivesAn index combining respiratory rate and oxygenation (ROX) has been introduced, and the ROX index is defined as the ratio of oxygen saturation by pulse oximetry/fraction of inspired oxygen to respiratory rate. In sepsis, hypoxemia and tachypnea are commonly observed. We performed this study to investigate the association between the ROX index and 28-day mortality in patients with sepsis or septic shock.MethodsThis retrospective study included 2862 patients. The patients were divided into three groups according to the ROX index: Group I (ROX index >20), Group II (ROX index >10 and ≤ 20), and Group III (ROX index ≤10).ResultsThe median ROX index was significantly lower in the nonsurvivors than in the survivors (12.8 and 18.2, respectively) (p < 0.001). The 28-day mortality rates in Groups I, II and III were 14.5%, 21.3% and 34.4%, respectively (p < 0.001). In the multivariable Cox regression analysis, Group III had an approximately 40% higher risk of death than Group I during the 28-day period (hazard ratio = 1.41, 95% confidence interval 1.13–1.76). The area under the curve of the ROX index was significantly higher than that of the quick Sequential Organ Failure Assessment score (p < 0.001).ConclusionsThe ROX index was lower in nonsurvivors than in survivors, and a ROX index less than or equal to 10 was an independent prognostic factor for 28-day mortality in patients with sepsis or septic shock. Therefore, the ROX index could be used as a prognostic marker in sepsis.     

Red cell distribution width is a prognostic factor in severe sepsis and septic shock

ObjectiveThis study was performed to investigate the association of red cell distribution width (RDW) with 28-day mortality in patients with severe sepsis and septic shock.MethodsWe performed a retrospective analysis of patients with severe sepsis and septic shock. Patients' demographic data, comorbidities, the blood test results including RDW at admission to the emergency department, and Acute Physiologic and Chronic Health Evaluation II score were compared between 28-day survivors and nonsurvivors. Red cell distribution width was categorized into tertiles as 14% or less, 14.1% to 15.7%, and 15.8% or greater. Multivariate Cox proportional hazards regression analysis was performed to determine the risk factors for mortality.ResultsA total of 566 patients were included, and overall mortality was 29%. Red cell distribution width was significantly higher in nonsurvivors than in survivors, and the corresponding mortality of patients with an RDW of 14% or less, 14.1% to 15.7%, and 15.8% or greater was 13.1%, 30.1%, and 44.9%, respectively (P < .001). In Cox proportional hazards analysis, groups with higher RDW are independently associated with 28-day mortality compared with groups with an RDW of 14.0% or less: RDW 14.1% to 15.7% (hazard ratio, 1.66; 95% confidence interval [CI], 1.00-2.76) and RDW of 15.8% or greater (hazard ratio, 2.57; 95% CI, 1.53-4.34). The area under the receiver operating curve of RDW was 0.68 (95% CI, 0.63-0.72).ConclusionRed cell distribution width is associated with 28-day mortality in patients with severe sepsis and septic shock.     

Serum total carbon dioxide as a prognostic factor for 28-day mortality in patients with sepsis

ObjectiveMetabolic acidosis is commonly associated with the disease severity in patients with sepsis or septic shock. This study was performed to investigate the association between serum total carbon dioxide (TCO₂₎ concentration and 28-day mortality in patients with sepsis.MethodsThis study was a multicenter retrospective cohort study of patients with sepsis or septic shock. The relationships between serum TCO₂ and 28-day mortality, bicarbonate, pH, lactate, and anion gap were determined with cubic spline curves. The patients were divided into four groups according to their serum TCO₂ concentration: Group I (TCO₂ > 20 mmol/l), Group II (15 < TCO₂ ≤ 20 mg/dl), Group III (10 < TCO₂ ≤ 15 mmol/l), and Group IV (TCO₂ ≤ 10 mmol/l).ResultsA total of 3168 patients were included in the analysis, and the overall mortality rate was 24.1%. Serum TCO₂ concentrations below 20 mmol/l showed an almost linear correlation with mortality as well as with lactate, bicarbonate, and pH. The 28-day mortality rates of Group I, II, III, and IV were 18.3%, 23.6%, 32.6%, and 50.0%, respectively (p < .001). In Multivariable Cox proportional hazard regression analysis, the groups with lower serum TCO₂ concentrations had a higher risk of 28-day mortality compared with Group I: Group II (Hazard ratio (HR), 1.35; 95% confidence interval (CI), 1.11–1.64), Group III (HR, 1.74; 95% CI, 1.37–2.21), and Group IV (HR, 2.72; 95% CI, 2.03–3.64).ConclusionsSerum TCO₂ concentrations of 20 mmol/l or less were associated with 28-day mortality in patients with sepsis.     

Plasma syndecan-1 is associated with fluid requirements and clinical outcomes in emergency department patients with sepsis

BackgroundDegradation of the endothelial glycocalyx is recognized as a major part of the pathophysiology of sepsis. Previous clinical studies, mostly conducted in intensive care settings, showed associations between glycocalyx shedding and clinical outcomes. We aimed to explore the association of plasma syndecan-1, a marker of glycocalyx degradation, with the subsequent fluid requirements and clinical outcomes of emergency department patients with sepsis.MethodsThis was a post hoc analysis of a randomized trial of fluid resuscitation in the emergency department. The study was conducted in the emergency department of an urban 1500-bed tertiary care center. The data of 95 adults who were diagnosed with sepsis-induced hypoperfusion and had undergone baseline syndecan-1 measurement were included. The syndecan-1 levels at baseline (T0) and hour 6 (T6) were studied to characterize their association with clinical outcomes, including subsequent fluid administration, organ failure outcomes and mortality.ResultsThe median syndecan-1 levels at T0 and T6 were 207 (IQR 135–438) and 207 (IQR 128–490) ng/ml, respectively. Syndecan-1 levels at T0 were correlated with baseline sequential organ failure assessment (SOFA) score (ρ = 0.35, p < 0.001). Syndecan-1 levels at both T0 and T6 were correlated with subsequent fluid administration over 24 and 72 h and associated with the diagnosis of septic shock, the maximum dose of vasopressors and the need for renal replacement therapy (p < 0.05). Higher syndecan-1 levels at T6 were associated with higher 90-day mortality (p = 0.03).ConclusionsIn the emergency department, syndecan-1 levels were associated with fluid requirements, sepsis severity, organ dysfunction, and mortality.     

Timeline of sepsis bundle component completion and its association with septic shock outcomes

PurposeTo assess the impact of the timeline of sepsis bundle completion with clinical outcomes in septic shock.Materials and methodsWe retrospectively studied adult (≥18 years) patients with septic shock from January 1, 2006, through May 31, 2018, who were admitted to the intensive care unit in Mayo Clinic, Rochester. We divided patients into three groups based on the SSC compliant 1) <1h, 2) 1.1 to 3 h, 3) >3 h after the time of septic shock diagnosis.ResultsWe enrolled 1052 septic shock patients, among 8% were in group 1, 26% in group 2, and the remaining in group 3. Those who completed all bundle components within 3 h had the lowest 28-day mortality (17.5% vs. 31.4%, p < .001) and higher survival at 90 days (HR = 0.67; 95% CI 0.55–0.80; p < .001). Sepsis bundle completion in <1 h had no significant advantage in 28-day mortality (21.5% vs.15.9%, p = .4) or 90-day survival compared with group 2 (HR = 1.08; 95% CI 0.77–1.53; p = .6).ConclusionsWe showed an association between the completion of SSC bundle components within three hours with lower mortality or earlier shock reversal. This relationship was not evident when compared to bundle completion in 1 h vs. within 3 h.     

Serum caspase 3 levels are associated with early mortality in severe septic patients

ObjectiveHigher caspase 3 activity has been found in lymphocytes of septic patients than of healthy controls. However, an association between serum caspase 3 levels at moment of severe sepsis diagnosis and mortality in septic patients has not been previously demonstrated, and this was the main objective of the present study.MethodsThis is an observational study of 216 patients with severe sepsis in 6 Spanish intensive care units. We collected serum samples at moment of severe sepsis diagnosis to determine levels of caspase 3 and caspase-cleaved cytokeratin (CCCK) 18. End point was 30-day mortality.ResultsWe found higher serum caspase 3 levels (P < .001) and caspase-cleaved cytokeratin 18 (P = .001) in nonsurvivors (n = 76) than in survivors (n = 140). Multiple binary logistic regression analysis showed that serum caspase 3 levels greater than 0.25 ng/mL were associated with 30-day mortality (odds ratio, 6.51; 95% confidence interval, 3.32-12.77; P < .001). Receiver operating characteristic analysis showed that the area under the curve to predict 30-day mortality for serum caspase 3 levels was 0.73 (95% confidence interval, 0.67-0.79; P < .001).ConclusionsThe major novel findings of our study were that there is an association between serum caspase 3 levels at moment of severe sepsis diagnosis and mortality in septic patients and that serum caspase 3 levels could be used as prognostic biomarker, and further studies are needed to corroborate these findings.     

Lymphocyte-to-monocyte ratio predicts mortality in cirrhotic patients with septic shock

IntroductionPatients with liver cirrhosis and septic shock have a significantly higher risk of mortality and morbidity compared with non-cirrhotic patients. The peripheral blood lymphocyte-to-monocyte ratio (LMR) can determine the prognosis of cirrhotic patients. Our study aimed to investigate the usefulness of LMR as a predictive marker of mortality risk in cirrhotic patients with septic shock.MethodsThis single-center, retrospective case-control study included adult patients who visited the emergency department between January 1, 2018 and June 30, 2020 and diagnosed with liver cirrhosis and septic shock. They were divided into survivor and non-survivor groups according to their survival status at the 60-day follow-up. We used a Cox proportional hazards regression model to identify independent factors associated with mortality risk and tested the mortality discriminative ability of those factors using the area under a receiver operating characteristic curve.ResultsA total of 93 patients were eligible for this study. Compared with the patients in the survivor group, those in the non-survivor group had significantly higher Child-Pugh (11 ± 2 vs. 9 ± 2, p < 0.001) and MELD scores (29 ± 6 vs. 22 ± 8, p < 0.001), higher serum international normalized ratio (1.7 vs.1.4, p = 0.03), bilirubin (6.0 vs. 3.3 mg/dL, p = 0.02), lactate (5.4 vs. 2.7 mmol/L, p < 0.01), creatinine (2.2 vs. 1.6 mg/dL, p = 0.04), higher neutrophil-to-lymphocyte ratio (13.0 vs. 10.3, p = 0.02), and lower LMR (1.1 vs. 2.3, p < 0.01). The LMR (adjusted hazard ratio [aHR] = 1.54, p = 0.01) and lactate (aHR = 1.03, p < 0.01) were identified as independent predictive factors for mortality in the multivariate regression model. Furthermore, LMR (area under curve [AUC]: 0.87) revealed a superior discrimination ability in mortality prediction compared with the Child-Pugh (AUC: 0.72) and MELD (AUC: 0.76) scores.ConclusionsThe LMR can be used to predict mortality risk in cirrhotic patients with septic shock.     

Severe sepsis and septic shock in patients transported by prehospital services versus walk in patients to the emergency department

BackgroundSepsis is a leading cause of death in the hospital for which aggressive treatment is recommended to improve patient outcomes. It is possible that sepsis patients brought in by emergency medical services (EMS) have a unique advantage in the emergency department (ED) which could improve sepsis bundle compliance.ObjectiveTo evaluate patient care processes and outcome differences between severe sepsis and septic shock patients in the emergency department who were brought in by EMS compared to non-EMS patients.MethodsWe performed a retrospective chart review of all severe sepsis and septic shock patients who declared in the ED during January 2012 thru December 2014. We compared differences in patient characteristics, patient care processes, sepsis bundle compliance metrics, and outcomes between both groups.ResultsOf the 1066 patients included in the study, 387 (36.6%) were brought in by EMS and 679 (63.7%) patients arrived via non-EMS transport. In the multivariate regression model, time of triage to sepsis declaration (coeff = −0.406; 95% CI = −0.809, −0.003; p = 0.048) and time of triage to physician (coeff = −0.543; 95% CI = −0.864, −0.221; p = 0.001) was significantly shorter for EMS patients. We found no statistical difference in adjusted individual sepsis compliance metrics, overall bundle compliance, or mortality between both groups.ConclusionEMS transported patients have quicker sepsis declaration times and are seen sooner by ED providers. However, we found no statistical difference in bundle compliance or patient outcomes between walk in patients and EMS transported patients.     

The role of the quick sequential organ failure assessment score (qSOFA) and modified early warning score (MEWS) in the pre-hospitalization prediction of sepsis prognosis

ObjectiveMany biomarkers and scoring systems to make clinical predictions about the prognosis of sepsis have been investigated. In this study, we aimed to assess the use of the quick sequential organ failure assessment score (qSOFA) and modified early warning score (MEWS) scoring systems in emergency health care services for sepsis to predict intensive care hospitalization and 28-day mortality.MethodPatients who arrived by ambulance at the Emergency Department (ED) of Dışkapı YıldırımBeyazıt Training and Research Hospital between January 2017 and December 2019, and who were diagnosed with sepsis and admitted to the hospital were included in the study. Demographic data and physiological parameters from 112 ambulance case delivery forms were recorded.QSOFA and MEWS scores were calculated from vital parameters.ResultsOf the 266 patients diagnosed with sepsis, 50% (n = 133) were female, and the mean age was 74.8 ± 13. The difference between the rate of intensive care (ICU) hospitalization and mortality for patients with a high MEWS and qSOFA score and patients whose MEWS and qSOFA score were lower was found to be statistically significant (p < 0.05). Thus, the criteria for MEWS and qSOFA could determine ICU hospitalization and early mortality. Those with a high MEWS value had a mortality rate approximately 1.24 times higher than those with a low MEWS value (p < 0.001, 95% CI: 1.110–1.385), while those with a high qSOFA score had a mortality rate approximately 2.0 times higher than those with a low qSOFA score (p < 0.001, 95% CI: 1.446–2.693). Those with a high MEWS were 1.34 times more likely than hose with a lower MEWS to require ICU hospitalization (p < 0.001, 95% CI: 1.1773–1.5131), while patients with a high qSOFA score were 3.21 times more likely than those with a lower qSOFA score to require ICU care (p < 0.001, 95% CI: 2.2289–4.6093).ConclusionAlthough qSOFA and MEWS are clinical scores used to identify septic patients outside the critical care unit, we believe that patients already diagnosed with sepsis can be assessed with qSOFA and MEWS prior to hospitalization to predict intensive care hospitalization and mortality. qSOFA was found be more valuable than MEWS in determining the prognosis of pre-hospitalization sepsis.     

Arterial vs venous lactate: Correlation and predictive value of mortality of patients with sepsis during early resuscitation phase

PurposeTo compare the lactate concentrations obtained from venous to those obtained from arterial blood in predicting hospital mortality of patients with sepsis and septic shock. To also assess lactate clearance as predictor for mortality.Methods100 patients with septic shock were prospectively enrolled. Serum was sampled at baseline and after 6 h of resuscitation from arterial and venous lines. Demographic, severity indices, hemodynamic measures as well as lactate clearance levels were noted. Data were analyzed for bias and precision.ResultsThere was correlation between venous and arterial lactate concentrations at the baseline (R = 0.68) and at the 6-hour time point (R = 0.95). Venous concentrations were consistently higher than those obtained from an arterial access by 0.684 mg/dL. Further, arterial lactate level > 3.2 mmol/L and clearance of <20% were considered the cutoff for the mortality risk. While only 8% of the patients with no risk died, all 20 patients who had lactate level > 3.2 mmol/L and clearance of <20% died within the hospital.ConclusionOur data suggests a strong correlation between arterial and peripheral venous the lactate levels and in the initial phase of resuscitation in septic shock patients we can use venous lactate level as biomarker instead of arterial lactate level. The study also showed that combining lactate levels and its clearance is a reliable predictor of mortality in sepsis.     

An Interdisciplinary Code Sepsis Team to Improve Sepsis-Bundle Compliance: A Quality Improvement Project

ProblemSepsis is one of the leading causes of mortality, with more than 700,000 hospitalizations and 200,000 deaths annually. Various tools exist to aid in the early identification and treatment of sepsis, including electronic alert systems, standardized order sets, nurse-initiated protocols (NIPs) and specially trained teams. Despite available guidelines, mortality rates for severe sepsis and septic shock are near 50%.MethodsThe aims of this rapid cycle quality improvement project were to develop and implement an interdisciplinary team to address early implementation of sepsis bundles in the emergency department and to compare sepsis bundle compliance 3 months pre- and 3 months postintervention implementation. The population included all patients above 18 years of age presenting to the emergency department with clinical indications of sepsis, severe sepsis, or septic shock. Data were collected via electronic health records (EHRs), switchboard-paging records, and a billing database.ResultsThe pre-post intervention analysis shows an improvement in time to each bundle element except antibiotics and completion of blood cultures. There were noteworthy changes in meeting bundle compliance in fluid resuscitation volume (χ² = 16.3, P ≤ 0.001): initial lactate collected within 180 min (χ² = 11.3, P ≤ 0.01) and time to second lactate within 360 min (χ² = 27.7, P ≤ 0.001). Mortality rates showed a steady decline from over 12% to 5%. No differences were found in mortality rates related to age or gender.DiscussionInterprofessional teams can use existing knowledge, skills, and tools to improve sepsis-bundle compliance and mortality outcomes in patients with sepsis presenting to the emergency department.     

Early lactate clearance in septic patients with elevated lactate levels admitted from the emergency department to intensive care: Time to aim higher?

Purpose

Septic patients with hyperlactatemia have increased mortality rates, irrespective of hemodynamic and oxygen-derived variables. The aims of the study are the following: (1) to ascertain whether lactate clearance (LC) (percentage change in lactate over unit time) predicts mortality in septic patients admitted to intensive care directly from the emergency department and (2) to calculate the optimal “cut-off” value for mortality prediction.

Methods

Three-year retrospective observational study of consecutive patients with severe sepsis and septic shock admitted to intensive care from the emergency department of a tertiary UK hospital. We calculated 6-hour LC, performed receiver operating characteristic analyses to calculate optimal cut-off values for initial lactate and LC, dichotomized patients according to the LC cut-off, and calculated hazard ratios using a Cox proportional hazards model.

Results

One hundred six patients were identified; 78, after exclusions. Lactate clearance was independently associated with 30-day mortality (P < .04); optimal cut-off, 36%. Mortality rates were 61.1% and 10.7% for patients with 6-hour LC 36% or less and greater than 36%, respectively. Hazard ratio for death with LC 36% or less was 7.33 (95% confidence interval, 2.17-24.73; P < .001).

Conclusions

Six-hour LC was independently associated with mortality, and the optimal cut-off value was 36%, significantly higher than previously reported. We would support further research investigating this higher LC as a distinct resuscitation end point in patients with severe sepsis and septic shock.     

Initial fluid resuscitation (30 mL/kg) in patients with septic shock: More or less?

ObjectivesThe 2018 Surviving Sepsis Campaign (SSC) recommends rapid administration of 30 mL/kg crystalloid fluids for hypotension or lactate ≥4 mmol/L in patients with septic shock; however, there is limited evidence to support this recommendation. The purpose of this study was to examine the relationship between initial fluid resuscitation doses and prognosis in patients with septic shock.MethodsThis was a multicenter prospective observational study of adult patients with septic shock who were admitted to four intensive care units (ICUs) in a total of three Jiangsu Province teaching hospitals over a 3-year span from May 8, 2018, to June 15, 2021. Each enrolled patients with septic shock was categorized into the low-volume (below 20 mL/kg fluid), medium-volume (20–30 mL/kg fluid) or high-volume (above 30 mL/kg fluid) fluid group according to the initial infusion dose given for fluid resuscitation. Various demographic attributes and other variables were collected from medical records. Logistic regression and Kaplan-Meier curve analysis were used to determine the relationship between initial fluid resuscitation doses and patient outcomes.Measurements and main resultsA total of 302 patients who presented to the ICU were diagnosed with septic shock. The 28-day mortality was highest in the high-volume group (48.3%) and lowest in the medium-volume group (26.3%, P < 0.05). Patients who completed 30 mL/kg initial fluid resuscitation in the first 1–2 h had the lowest 28-day mortality rate (22.8%, P < 0.05). Logistic regression showed that a medium initial fluid volume dose was an independent protective factor, with the odds ratio (OR) indicating significantly decreased mortality (OR, 0.507; 95% confidence interval, 0.310–0.828; P = 0.007; P < 0.05). A Kaplan-Meier curve stratified by initial fluid resuscitation dose was constructed for the probability of 28-day mortality. The medium-volume fluid group showed a significantly lower 28-day mortality rate than the high-volume group or the low-volume group (log-rank test, P = 0.0016).ConclusionIn septic shock patients, an initial fluid resuscitation rate of 20–30 mL/kg within the first hour may be associated with reduced 28-day mortality; however, this result needs to be confirmed by further high-quality randomized controlled clinical trials.Trial registrationChinese Clinical Trial Registry, ChiCTR-OOC-17013223. Registered 2 November 2017, http://www.chictr.org.cn/showproj.aspx?proj=22674     

Alactic base excess is an independent predictor of death in sepsis: A propensity score analysis

PurposeAlactic base excess (ABE) is a novel biomarker defined as the sum of lactate and standard base excess and estimates the renal capability of handling acid-base disturbances in sepsis. The objective of this study is to see if ABE is an independent predictor of mortality in septic patients with and without renal dysfunction.Materials and methodsWe retrospectively studied 1178 patients with sepsis and septic shock. Patients were divided according to ABE values: 1) negative ABE (<−3 mmol/L); 2) neutral ABE (≥ − 3 and < 4 mmol/L); and 3) positive ABE (≥4 mmol/L). The effect of ABE on mortality was evaluated using Cox regression weight by inverse probability weighting (IPWT) analysis after propensity score assessment. Additionally, we performed a stratified analysis in patients with GFR > 60 mL/min/1.73 m2.ResultsNegative ABE patients had higher mortality than patients with neutral ABE (adjusted HR 1.43; 95%CI 1.02–2.01). Also, in patients with GFR > 60 mL/min/1.73 m2 (n = 493), we observed higher mortality in patients with negative ABE (adjusted HR 2.43; 95%CI 1.07–5.53).ConclusionsNegative ABE is an independent predictor of in-hospital mortality in septic patients with and without renal dysfunction.     

The use of the pulse oximetric saturation/fraction of inspired oxygen ratio for risk stratification of patients with severe sepsis and septic shock

PurposeOur aims were to determine whether the pulse oximetric saturation/fraction of inspired oxygen (S/F) can be used for the early identification of patients with sepsis who are at increased risk for death and to compare the S/F ratio with the Pao₂/fraction of inspired oxygen (P/F) ratio.Materials and MethodsThis is a retrospective cohort study in 260 patients admitted to 2 tertiary mixed intensive care units (ICUs) with severe sepsis or septic shock. We studied the association between tertiles of S/F ratio and ICU mortality using Cox regression. Subsequently, we compared corresponding measurements of S/F ratio and P/F ratio upon ICU admission using Pearson correlation coefficient (r).ResultsWe observed an overall case fatality of 72 (28%) of 260. After adjustment for severity of the illness, the lowest tertile (S/F, < 164) at ICU admission was associated with increased mortality (hazard ratio, 1.87 [95% confidence interval, 1.02-3.41]) comparing to the highest tertile (S/F, > 236). The S/F ratio was correlated with P/F ratio (r = 0.48; P < .0001).ConclusionA low S/F at ICU admission is associated with increased risk of death in patients with severe sepsis or septic shock.     

Can corticosteroids reduce the mortality of patients with severe sepsis? A systematic review and meta-analysis

BackgroundThe effects of corticosteroids on clinical outcomes of patients with sepsis remains controversial. We aimed to further determine the effectiveness of corticosteroids in reducing mortality in adult patients with severe sepsis by comparison with placebo.MethodsPubmed, Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL) as well as the Information Sciences Institute (ISI) Web of Science were searched for all controlled studies that compared corticosteroids and placebo in adult patients with severe sepsis. The primary outcome was the mortality 28-day mortality and the secondary outcomes were mortality at longest follow up, occurrence, and reoccurrence of septic shock.ResultsA total of 19 trials involving 7035 patients were pooled in our final analyses. No significant heterogeneity was found in any of the outcome measures. Compared with placebo, corticosteroids were associated with a lower 28-day mortality (RR 0.91, 95% CI 0.85–0.98, Z = 2.57, P = 0.01) both in patients having sepsis and in those who developed septic shock (RR 0.92, 95% CI 0.85–0.99, Z = 2.19, P = 0.03), while no significant difference was found in mortality with the longest follow up in patients either having sepsis (RR 0.94, 95% CI 0.89–1.00, Z = 1.93, P = 0.05), or occurrence (RR 0.83, 95% CI 0.56–1.24, Z = 0.90, P = 0.37) or reoccurrence of septic shock (RR 1.08, 95% CI 1.00–1.16, Z = 1.89, P = 0.06).ConclusionsCorticosteroids were effective in reducing the 28-day mortality in patients with severe sepsis and in those with septic shock.     

Prognostic performance of disease severity scores in patients with septic shock presenting to the emergency department

BackgroundAn accurate disease severity score that can quickly predict the prognosis of patients with sepsis in the emergency department (ED) can aid clinicians in distributing resources appropriately or making decisions for active resuscitation measures. This study aimed to compare the prognostic performance of quick sequential organ failure assessment (qSOFA) with that of other disease severity scores in patients with septic shock presenting to an ED.MethodsWe performed a prospective, observational, registry-based study. The discriminative ability of each disease severity score to predict 28-day mortality was evaluated in the overall cohort (which included patients who fulfilled previously defined criteria for septic shock), the newly defined sepsis subgroup, and the newly defined septic shock subgroup.ResultsA total of 991 patients were included. All disease severity scores had poor discriminative ability for 28-day mortality. The sequential organ failure assessment and acute physiology and chronic health evaluation II scores had the highest area under the receiver-operating characteristic curve (AUC) values, which were significantly higher than the AUC values of other disease severity scores in the overall cohort and the sepsis and septic shock subgroups. The discriminative ability of each disease severity score decreased as the mortality rate of each subgroup increased.ConclusionsAll disease severity scores, including qSOFA, did not display good discrimination for 28-day mortality in patients with serious infection and refractory hypotension or hypoperfusion; additionally, none of the included scoring tools in this study could consistently predict 28-day mortality in the newly defined sepsis and septic shock subgroups.     

Efficacy and safety of corticosteroids for septic shock in immunocompromised patients: A cohort study from MIMIC

BackgroundCorticosteroids have been widely used as adjunct therapy for septic shock for many decades, but both the efficacy and safety remain unclear. The study was designed to investigate overall benefits and potential risks of corticosteroids in immunocompromised patients with septic shock.MethodsThe Medical Information Mart for Intensive Care III (MIMIC-III) database was employed to conduct a cohort study. Immunocompromised patients with septic shock were enrolled and categorized by whether exposure to intravenous corticosteroids. Cox Proportional-Hazards models were used to control for confounders and assess the relationship between corticosteroids use and mortality.ResultsA total of 866 patients were enrolled in this study, including 395 in the corticosteroids group and 471 in the non-corticosteroids group. Corticosteroids infusion was not associated with improved 30-day mortality in overall immunocompromised population [34.7% vs 32.1%; adjusted hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.87–1.43, p = 0.37]. The mortality effects were similar in 90-day, 180-day, 1-year and hospital mortality. For the subgroup of patients with metastatic cancer, corticosteroids infusion was associated with a statistically significant increase in the 30-day mortality risk (HR 1.58, 95% CI 1.06–2.37; p = 0.02). Corticosteroids had adverse effects on hemodynamic stability, prolonged ICU and hospital duration, and increased risk of hyperglycemia.ConclusionsCorticosteroids therapy for the maintenance of blood pressure was not associated with improved mortality or hemodynamic stability in overall immunocompromised population with septic shock. Future randomized clinical trials are required to validate the effects of corticosteroids for septic shock in the special immunocompromised population.     

Presepsin as a powerful monitoring tool for the prognosis and treatment of sepsis: A multicenter prospective study

Presepsin is a protein whose levels increase specifically in the blood of patients with sepsis. It is proposed as a diagnostic and prognostic marker for assessing the degree of sepsis severity. The present multicenter prospective study compared the clinical utility of presepsin with other conventional sepsis biomarkers including procalcitonin, interleukin-6, and C-reactive protein for evaluating the severity of sepsis during follow-up. Patients with sepsis (n = 103) admitted to the emergency room or intensive care unit were enrolled in this study and classified into 3 diagnostic groups: sepsis, severe sepsis, and septic shock. Blood samples were obtained from each patient on admission and after 1, 3, 5, and 7 days. The patients were further divided into the favorable and unfavorable prognosis groups on the basis of several indicators of sepsis severity (i.e., Sequential Organ Failure Assessment score, and Acute Physiology and Chronic Health Evaluation II score). The patients in the favorable prognosis group exhibited significant decreases in all biomarker levels on days 3 and 7 after admission. In the unfavorable prognosis group, only presepsin levels did not decrease significantly during follow-up. The period of antibiotics treatment in the unfavorable prognosis group was significantly longer than those in the favorable prognosis group (P < 0.05). The unfavorable prognosis group had significantly higher 28-day mortality than the favorable prognosis group (P < 0.05). Therefore, the results suggest that presepsin levels correlated with the severity of sepsis during follow-up in comparison with other conventional sepsis biomarkers.     

Soluble receptor for advanced glycation end products predicts 28-day mortality in critically ill patients with sepsis

Abstract

Objective. Multiple biomarkers are used to assess sepsis severity and prognosis. Increased levels of the soluble receptor for advanced glycation end products (sRAGE) were previously observed in sepsis but also in end-organ injury without sepsis. We evaluated associations between sRAGE and (i) 28-day mortality, (ii) sepsis severity, and (iii) individual organ failure. Traditional biomarkers procalcitonin (PCT), C-reactive protein (CRP) and lactate served as controls. Methods. sRAGE, PCT, CRP, and lactate levels were observed on days 1 (D1) and 3 (D3) in 54 septic patients. We also assessed the correlation between the biomarkers and acute respiratory distress syndrome (ARDS), acute kidney injury (AKI) and acute heart failure. Results. There were 38 survivors and 16 non-survivors. On D1, non-survivors had higher sRAGE levels than survivors (p = 0.027). On D3, sRAGE further increased only in non-survivors (p < 0.0001) but remained unchanged in survivors. Unadjusted odds ratio (OR) for 28-day mortality was 8.2 (95% CI: 1.02–60.64) for sRAGE, p = 0.048. Receiver operating characteristic analysis determined strong correlation with outcome on D3 (AUC = 0.906, p < 0.001), superior to other studied biomarkers. sRAGE correlated with sepsis severity (p < 0.00001). sRAGE showed a significant positive correlation with PCT and CRP on D3. In patients without ARDS, sRAGE was significantly higher in non-survivors (p < 0.0001) on D3. Conclusion. Increased sRAGE was associated with 28-day mortality in patients with sepsis, and was superior compared to PCT, CRP and lactate. sRAGE correlated with sepsis severity. sRAGE was increased in patients with individual organ failure. sRAGE could be used as an early biomarker in prognostication of outcome in septic patients.