An increase in red blood cell distribution width from baseline predicts mortality in patients with severe sepsis or septic shock

Introduction

A potential independent association was recently demonstrated between high red blood cell distribution width (RDW) and the risk of all-cause mortality in critically ill patients, although the mechanism underlying this relationship remains unclear. Little is known about the impact changes in RDW may have on survival in critically ill patients. Therefore, we investigated the prognostic significance of changes in RDW during hospital stay in patients with severe sepsis or septic shock.

Methods

We prospectively enrolled 329 patients who were admitted to the emergency department (ED) and received a standardized resuscitation algorithm (early-goal directed therapy) for severe sepsis or septic shock. The relationship between the changes in RDW during the first 72 hours after ED admission and all-cause mortality (28-day and 90-day) were analyzed by categorizing the patients into four groups according to baseline RDW value and ΔRDW_72hr-adm (RDW at 72 hours – RDW at baseline).

Results

The 28-day and 90-day mortality rates were 10% and 14.6%, respectively. Patients with increased RDW at baseline and ΔRDW_72hr-adm >0.2% exhibited the highest risks of 28-day and 90-day mortality, whereas the patients with normal RDW level at baseline and ΔRDW_72hr-adm ≤0.2% (the reference group) had the lowest mortality risks. For 90-day mortality, a significantly higher mortality risk was observed in the patients whose RDW increased within 72 hours of ED admission (normal RDW at baseline and ΔRDW_72hr-adm >0.2%), compared to the reference group. These associations remained unaltered even after adjusting for age, sex, Sequential Organ Failure Assessment (SOFA) score, Charlson Comorbidity Index, renal replacement therapy, albumin, hemoglobin, lactate, C-reactive protein and infection sites in multivariable models.

Conclusions

We found that an increase in RDW from baseline during the first 72 hours after hospitalization is significantly associated with adverse clinical outcomes. Therefore, a combination of baseline RDW value and an increase in RDW can be a promising independent prognostic marker 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.     

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.     

Association of ischemia modified albumin with mortality in qSOFA positive sepsis patients by sepsis-3 in the emergency department

BackgroundThe early detection and treatment of sepsis and septic shock patients in emergency departments are critical. Ischemia modified albumin (IMA) is a biomarker produced by ischemia and oxygen free radicals which are related to the pathogenesis of sepsis-induced organ dysfunction. This study aimed to investigate whether IMA was associated with short-term mortality in quick sequential organ failure assessment (qSOFA)-positive sepsis or septic shock patients screened by the sepsis management program.MethodFrom September 2019 to April 2020, patients who arrived at the emergency departments with qSOFA-positive sepsis or septic shock were included in this retrospective observational study.ResultsAmong 124 patients analyzed, IMA was higher in the non-surviving group than in the surviving group (92.6 ± 8.1 vs. 86.8 ± 6.2 U/mL, p < 0.001). The area under the receiver operating characteristics curve was 0.703 (95% CI: 0.572–0.833, p < 0.001). The optimal IMA cutoff was 90.45 (sensitivity 60.9%, specificity 79.2%). IMA values were independently associated with 28-day mortality in the multivariate Cox proportional hazard model (adjusted hazard ratio (aHR) = 1.16, 95% CI: 1.06–1.27, p < 0.01).ConclusionsIn this study, we showed that IMA in the emergency departments was associated with 28-day mortality in qSOFA-positive sepsis and septic shock patients. Further studies are needed to evaluate the clinical value of IMA as a useful biomarker in large populations and multicenter institutions.     

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.     

Red blood cell distribution width is an independent predictor of mortality in patients with gram-negative bacteremia

Red blood cell distribution width (RDW) is known to be a predictor of severe morbidity and mortality in some chronic diseases such as congestive heart failure. However, to our knowledge, little is known about RDW as a predictor of mortality in patients with Gram-negative bacteremia, a major nosocomial cause of intra-abdominal infections, urinary tract infections, and primary bacteremia. Therefore, we investigated whether RDW is an independent predictor of mortality in patients with Gram-negative bacteremia. Clinical characteristics, laboratory parameters, and outcomes of 161 patients with Gram-negative bacteremia from November 2010 to March 2011 diagnosed at Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, were retrospectively analyzed. The main outcome measure was 28-day all-cause mortality. The 28-day mortality rate was significantly higher in the increased RDW group compared with the normal RDW group (P < 0.001). According to multivariate Cox proportional hazard analysis, RDW levels at the onset of bacteremia (per 1% increase, P = 0.036), the Charlson index (per 1-point increase, P < 0.001), and the Sequential Organ Failure Assessment score (per 1-point increase, P = 0.001) were independent risk factors for 28-day mortality. Moreover, the nonsurvivor group had significantly higher RDW levels 72 h after the onset of bacteremia than did the survivor group (P = 0.001). In addition, the area under the curve of RDW at the onset of bacteremia, the 72-h RDW, and the Sequential Organ Failure Assessment score for 28-day mortality were 0.764 (P = 0.001), 0.802 (P < 0.001), and 0.703 (P = 0.008), respectively. Red blood cell distribution width at the onset of bacteremia was an independent predictor of mortality in patients with Gram-negative bacteremia. Also, 72-h RDW could be a predictor for all-cause mortality in patients with Gram-negative bacteremia.     

Epidemiology of severe sepsis in Japanese intensive care units: A prospective multicenter study

Severe sepsis is a leading cause of morbidity and mortality in the intensive care unit (ICU). We conducted a prospective multicenter study to evaluate epidemiology and outcome of severe sepsis in Japanese ICUs. The patients were registered at 15 general critical care centers in Japanese tertiary care hospitals when diagnosed as having severe sepsis. Of 14,417 patients, 624 (4.3%) were diagnosed with severe sepsis. Demographic and clinical characteristics at enrollment (Day 1), physiologic and blood variables on Days 1 and 4, and mortality were evaluated. Mean age was 69.0 years, and initial mean Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores were 23.4 and 8.6, respectively. The 28-day mortality was 23.1%, and overall hospital mortality was 29.5%. SOFA score and disseminated intravascular coagulation (DIC) score were consistently higher in nonsurvivors than survivors on Days 1 and 4. SOFA score, DIC score on Days 1 and 4, and hospital mortality were higher in patients with than without septic shock. SOFA score on Days 1 and 4 and hospital mortality were higher in patients with than without DIC. Logistic regression analyses showed age, presence of septic shock, DIC, and cardiovascular dysfunction at enrollment to be predictors of 28-day mortality and presence of comorbidity to be an additional predictor of hospital mortality. Presence of septic shock or DIC resulted in approximately twice the mortality of patients without each factor, whereas the presence of comorbidity may be a significant predictor of delayed mortality in severe sepsis.     

Reduction in procalcitonin level and outcome in critically ill children with severe sepsis/septic shock—A pilot study

PurposeTo investigate if reduction in procalcitonin (PCT) provides useful information about 28-day mortality in children with severe sepsis or septic shock.Materials and MethodsDesign: Prospective observational study. Setting: Mixed adult-pediatric intensive care unit in a teaching hospital. Subjects: Children up to 18 years of age admitted with severe sepsis or septic shock between March 2011 and June 2013. Procalcitonin measured using electrochemiluminescence immunoassay on the day of admission with sepsis (D0) and 72-96 hours later (D4). Reduction in PCT from D0 to D4 correlated with the primary outcome, that is, 28-day mortality.ResultsTwenty-five children of median age of 14 years (range, 6-18 years) were included, but 5 died before D4 after admission. Six of the remaining 20 children died between D4 and D28, and 14 survived to D28. At admission, the median of the Pediatric Risk of Mortality III score was 10 (interquartile range [IQR], 5-16) and that of the Sequential Organ Failure Assessment score was 11 (IQR, 7-15). The median PCT level was 9.7 ng/mL on D0 (n = 25) and 3.3 ng/mL on D4 (n = 20). On D0, the median PCT level was 25.0 ng/mL in the 14 survivors and 8.4 ng/mL in the 11 nonsurvivors (P = .075). On D4, the median PCT level was 3.1 ng/mL in the 14 survivors and 4.5 ng/mL in the 6 nonsurvivors who lived to D4 (P = .71); the reduction in PCT (D0 minus D4) was 17.3 ng/mL (IQR, 3.5-38.0 ng/mL) in the survivors and −1.1 ng/mL (IQR, −24.9 to 8.6 ng/mL) in the 6 nonsurvivors (P = .017). Percent reduction in PCT (100 * [D0 − D4]/D0) was 75.5% (IQR, 54.8%-80.7%) in the survivors and −200.3% (IQR, −937.8% to 42.4%) in the 6 nonsurvivors (P = .006).ConclusionThis small pilot study suggests that further studies are indicated to determine whether children with severe sepsis or septic shock are less likely to die if they have a reduction in PCT more than 50% in the first 4 days in intensive care.     

Elevated red cell distribution width at initiation of critical care is associated with mortality in surgical intensive care unit patients

PurposeRecent evidence suggests that red cell distribution width (RDW) is associated with mortality in mixed cohorts of critically ill patients. Our goal was to investigate whether elevated RDW at initiation of critical care in the intensive care unit (ICU) is associated with 90-day mortality in surgical patients.MethodsWe performed a retrospective, single-center cohort study. Normal RDW was defined as 11.5%–14.5%. To investigate the association of admission RDW with 90-day mortality, we performed a logistic regression analysis, controlling for age, sex, race, body mass index, Nutrition Risk Screening 2002 score, Acute Physiology and Chronic Health Evaluation II score, hospital length of stay, as well as levels of creatinine, albumin, and mean corpuscular volume.Results500 patients comprised the analytic cohort; 47% patients had elevated RDW and overall 90-day mortality was 28%. Logistic regression analysis demonstrated that patients with elevated RDW had a greater than two-fold increased odds of mortality (OR 2.28: 95%CI 1.20–4.33) compared to patients with normal RDW.ConclusionsElevated RDW at initiation of care is associated with increased odds of 90-day mortality in surgical ICU patients. These data support the need for prospective studies to determine whether RDW can improve risk stratification in surgical ICU patients.     

尿酸联合红细胞分布宽度对脓毒症患者短期结局的预测价值

目的探讨尿酸联合红细胞分布宽度（RDW）在评估脓毒症患者短期临床预后中的诊断价值。 方法将216例脓毒症患者根据尿酸及RDW水平分为A组（尿酸≤ 258 μmol/L且RDW ≤ 14.1%，50例）、B组（尿酸≤ 258 μmol/L且RDW>14.1%，58例）、C组（尿酸>258 μmol/L且RDW ≤ 14.1%，58例）、D组（尿酸>258 μmol/L且RDW>14.1%，50例）。对各组患者的住院期间病死率、30 d病死率、尿酸及RDW进行比较；同时，应用Kaplan-Meier生存曲线比较各组患者随访30 d生存曲线变化；应用受试者工作特征（ROC）曲线判断尿酸、RDW及二者联合指标对脓毒症患者住院期间及随访30 d死亡风险的预测价值。 结果4组患者间住院期间病死率、30 d病死率、尿酸及RDW间比较，差异均有统计学意义（F= 16.211、19.206、132.755、59.771，P均<0.05）。进一步两两比较发现，住院期间病死率仅D组显著高于A组[40.00%（20/50）vs. 8.00%（4/50），P<0.008]，且与C组及D组比较，A组的30 d病死率[34.48%（20/58）、52.00%（26/50）、12.00%（6/50），P均<0.008]及A组与B组的尿酸水平[（411 ± 115）、（412 ± 117）、（170 ± 61）、（148 ± 66）μmol/L，P均<0.05]均显著较低；同时，B组与D组的RDW均显著高于A组与C组[（15.9 ± 2.0）%、（16.0 ± 2.1）%、（13.3 ± 0.6）%、（13.2 ± 0.6）%，P均< 0.05]。而C组与D组间住院期间病死率（P>0.008）、30 d病死率（P>0.008）及尿酸水平（P>0.05）的比较，差异均无统计学意义。4组患者间的Kaplan-Meier生存曲线比较，差异有统计学意义（χ²= 14.102，P= 0.003），且C组及D组的生存曲线均显著低于A组（P均<0.008）。ROC曲线显示，尿酸联合RDW对脓毒症患者住院期间及随访30 d死亡风险的预测价值均明显优于尿酸（Z= 2.043，P= 0.041；Z= 2.012，P= 0.044）及RDW（Z= 2.245，P= 0.025；Z= 2.322，P= 0.020）。 结论尿酸联合RDW能较好地预测脓毒症患者短期临床结局。     

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.     

Clinical spectrum, frequency, and significance of myocardial dysfunction in severe sepsis and septic shock

ObjectiveTo determine the frequency and spectrum of myocardial dysfunction in patients with severe sepsis and septic shock using transthoracic echocardiography and to evaluate the impact of the myocardial dysfunction types on mortality.Patients and MethodsA prospective study of 106 patients with severe sepsis or septic shock was conducted from August 1, 2007, to January 31, 2009. All patients underwent transthoracic echocardiography within 24 hours of admission to the intensive care unit. Myocardial dysfunction was classified as left ventricular (LV) diastolic, LV systolic, and right ventricular (RV) dysfunction. Frequency of myocardial dysfunction was calculated, and demographic, hemodynamic, and physiologic variables and mortality were compared between the myocardial dysfunction types and patients without cardiac dysfunction.ResultsThe frequency of myocardial dysfunction in patients with severe sepsis or septic shock was 64% (n=68). Left ventricular diastolic dysfunction was present in 39 patients (37%), LV systolic dysfunction in 29 (27%), and RV dysfunction in 33 (31%). There was significant overlap. The 30-day and 1-year mortality rates were 36% and 57%, respectively. There was no difference in mortality between patients with normal myocardial function and those with left, right, or any ventricular dysfunction.ConclusionMyocardial dysfunction is frequent in patients with severe sepsis or septic shock and has a wide spectrum including LV diastolic, LV systolic, and RV dysfunction types. Although evaluation for the presence and type of myocardial dysfunction is important for tailoring specific therapy, its presence in patients with severe sepsis and septic shock was not associated with increased 30-day or 1-year mortality.     

Red cell distribution width as a predictor of mortality in organophosphate insecticide poisoning

Objective

Suicide by organophosphate insecticide (OPI) poisoning is a major clinical concern (predominantly in developing countries), and 200 000 deaths occur annually worldwide. Red cell distribution width (RDW) has been used to predict outcome in several clinical conditions. Here, we aimed to investigate the relationship between the RDW and 30-day mortality during OPI poisoning.

Methods

This retrospective analysis was performed between January 2008 and July 2013 in patients admitted to the emergency department after OPI poisoning. A Kaplan-Meier 30-day survival curve was analyzed in patients stratified according to the optimal cut-off point of RDW defined using a receiver operating characteristic (ROC) curve. Multivariate Cox proportional hazards analyses were conducted to determine the independent prognostic factors for 30-day mortality.

Results

Among 102 patients, 21 died, yielding a mortality of 20.6%. Elevated RDW was significantly associated with early mortality in patients with OPI poisoning. Levels of RDW that exceeded 13.5% (hazard ratio, 2.64; 95% confidence interval [CI], 1.05-6.60) were associated with increased mortality in the multivariate analysis. The area under the ROC curve of RDW was 0.675 (95% CI, 0.522-0.829).

Conclusions

This study showed that RDW is an independent predictor of 30-day mortality in patients with OPI poisoning.     

Red cell distribution width as a prognostic marker in patients with community-acquired pneumonia

Background

Red cell distribution width (RDW) is associated with mortality in both the general population and in patients with certain diseases. However, the relationship between RDW and mortality in patients with community-acquired pneumonia (CAP) is unknown. The objective of this study was to evaluate the association of RDW with mortality in patients with CAP.

Methods

We performed a retrospective analysis of a prospective registry database of patients with CAP. Red cell distribution width was organized into quartiles. The pneumonia severity index (PSI) and CURB-65 were calculated. The primary outcome was 30-day mortality. Secondary outcomes included the length of hospital stay, admission to the intensive care unit, vasopressor use, and the need for mechanical ventilation.

Results

A total of 744 patients were included. The PSI and CURB-65 were higher in patients with a high RDW. Multivariate logistic regression analysis identified higher categories of RDW, PSI, CURB-65, and albumin as statistically significant variables. Thirty-day mortality was significantly higher in patients with a higher RDW. Among the secondary outcomes, the length of hospital stay and vasopressor use were significantly different between the groups. In a Cox proportional hazard regression analysis, patients with higher categories of RDW exhibited increased mortality before and after adjustment of the severity scales. Receiver operating characteristics curves demonstrated improved mortality prediction when RDW was added to the PSI or CURB-65.

Conclusion

Red cell distribution width was associated with 30-day mortality, length of hospital stay, and use of vasopressors in hospitalized patients with CAP. The inclusion of RDW improved the prognostic performance of the PSI and CURB-65.     

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.     

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.     

IgMA-enriched immunoglobulin in neutropenic patients with sepsis syndrome and septic shock: a randomized, controlled, multiple-center trial

OBJECTIVE: To evaluate the effect of intravenous IgMA-enriched immunoglobulin (ivIGMA) therapy on mortality in neutropenic patients with hematologic malignancies and sepsis syndrome or septic shock. DESIGN: Multiple-center, prospective randomized, controlled study. SETTING: Six university hospitals in Germany. PATIENTS: Patients were 211 neutropenic patients with sepsis syndrome or septic shock after chemotherapy for severe hematologic disorders between 1992 and 1999. INTERVENTIONS: Patients received 1300 mL of ivIGMA (7.8 g IgM, 7.8 g IgA, and 49.4 g IgG) infused intravenously within a period of 72 hrs or human albumin according to the same schedule as ivIGMA. MEASUREMENTS AND MAIN RESULTS: All-cause mortality at 28 days, sepsis-related mortality at 28 days, all-cause mortality at 60 days, mortality from septic shock, and mortality from microbiologically proven Gram-negative sepsis and septic shock were recorded. Immunoglobulin had no benefit over human albumin. The 28-day mortality rate was 26.2% and 28.2% in the ivIGMA and control patients, respectively (difference, 2.0% [95% confidence interval, -10.2 to 14.2 percentage points]). Likewise, the 60-day mortality rate did not differ between both arms (29.6% vs. 34.7% in the ivIGMA and control patients, respectively). Mortality rates in patients with sepsis syndrome (17.1% vs. 16.7%) and septic shock (51.9% vs. 54.8%) were also found to be similar between both groups. CONCLUSIONS: Intravenous ivIGMA had no beneficial effects in neutropenic patients with hematologic malignancies and sepsis syndrome and septic shock.     

Derivation of a screen to identify severe sepsis and septic shock in the ED-BOMBARD vs. SIRS and qSOFA

Study objectiveTo predict severe sepsis/septic shock in ED patients.MethodsWe conducted a retrospective case-control study of patients ≥18 admitted to two urban hospitals with a combined ED census of 162,000.Study cases included patients with severe sepsis/septic shock admitted via the ED. Controls comprised admissions without severe sepsis/septic shock. Using multivariate logistic regression, a prediction rule was constructed. The model's AUROC was internally validated using 1000 bootstrap samples.Results143 study and 286 control patients were evaluated. Features predictive of severe sepsis/septic shock included: SBP ≤ 110 mm Hg, shock index/SI ≥ 0.86, abnormal mental status or GCS < 15, respirations ≥ 22, temperature ≥ 38C, assisted living facility residency, disabled immunity.Two points were assigned to SI and temperature with other features assigned one point (mnemonic: BOMBARD). BOMBARD was superior to SIRS criteria (AUROC 0.860 vs. 0.798, 0.062 difference, 95% CI 0.022–0.102) and qSOFA scores (0.860 vs. 0.742, 0.118 difference, 95% CI 0.081–0.155) at predicting severe sepsis/septic shock. A BOMBARD score ≥ 3 was more sensitive than SIRS ≥ 2 (74.8% vs. 49%, 25.9% difference, 95% CI 18.7–33.1) and qSOFA ≥ 2 (74.8% vs. 33.6%, 41.2% difference, 95% CI 33.2–49.3) at predicting severe sepsis/septic shock. A BOMBARD score ≥ 3 was superior to SIRS ≥ 2 (76% vs. 45%, 32% difference, 95% CI 10–50) and qSOFA ≥ 2 (76% vs. 29%, 47% difference, 95% CI 25–63) at predicting sepsis mortality.ConclusionBOMBARD was more accurate than SIRS and qSOFA at predicting severe sepsis/septic shock and sepsis mortality.     

Red Cell Distribution Width Is Independently Associated with Mortality in Sepsis

BackgroundMortality in sepsis remains high. Studies on small cohorts have shown that red cell distribution width (RDW) is associated with mortality. The aim of this study was to validate these findings in a large multicenter cohort.MethodsWe conducted this retrospective analysis of the multicenter eICU Collaborative Research Database in 16,423 septic patients. We split the cohort in patients with low (≤15%; n = 7,129) and high (>15%; n = 9,294) RDW. Univariable and multivariable multilevel logistic regressions were used to fit regression models for the binary primary outcome of hospital mortality and the secondary outcome intensive care unit (ICU) mortality with hospital unit as random effect. Optimal cutoffs were calculated using the Youden index.ResultsPatients with high RDW were more often older than 65 years (57% vs. 50%; p < 0.001) and had higher Acute Physiology and Chronic Health Evaluation (APACHE) IV scores (69 vs. 60 pts.; p < 0.001). Both hospital (adjusted odds ratios [aOR] 1.18; 95% CI: 1.16–1.20; p < 0.001) and ICU mortality (aOR 1.16; 95% CI: 1.14–1.18; p < 0.001) were associated with RDW as a continuous variable. Patients with high RDW had a higher hospital mortality (20 vs. 9%; aOR 2.63; 95% CI: 2.38–2.90; p < 0.001). This finding persisted after multivariable adjustment (aOR 2.14; 95% CI: 1.93–2.37; p < 0.001) in a multilevel logistic regression analysis. The optimal RDW cutoff for the prediction of hospital mortality was 16%.ConclusionWe found an association of RDW with mortality in septic patients and propose an optimal cutoff value for risk stratification. In a combined model with lactate, RDW shows equivalent diagnostic performance to Sequential Organ Failure Assessment (SOFA) score and APACHE IV score.     

Association Between Red Cell Distribution Width and Hospital Mortality in Patients with Sepsis

ObjectiveSepsis is the leading cause of death in patients admitted to adult intensive care units (ICUs). We aimed to determine the predictive value of red blood cell distribution width (RDW) in patients with sepsis in a large cohort.MethodsThis retrospective observational study used data from the eICU Collaborative Research Database. The prognostic value of RDW was investigated using the receiver operating characteristic (ROC) curve, multiple logistic regression model, integrated discriminatory index (IDI), and net reclassification index (NRI).ResultsIn total, 9743 patients were included. The area under the ROC curve of the RDW for predicting hospital mortality was 0.631 (95% confidence interval [CI]: 0.616–0.645). Based on the multiple logistic regression model, an RDW of ≥14.5% was correlated with hospital mortality, regardless of Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation IV (APACHE IV) scores (odds ratio [OR]: 1.838, 95% CI: 1.598–2.119). Using SOFA and APACHE IV scores as reference, the IDI and continuous NRI of RDW for hospital mortality was about 0.3 and 0.014, respectively.ConclusionsThe RDW may be useful in predicting hospital mortality in patients with sepsis, offering extra prognostic value beyond SOFA and APACHE IV scores.