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.     

Epidemiology and outcome of severe pneumococcal pneumonia admitted to intensive care unit: a multicenter study

ABSTRACT: INTRODUCTION: Community-acquired pneumonia (CAP) account for a high proportion of ICU admissions, with Streptococcus pneumoniae being the main pathogen responsible for these infections. However, little is known on the clinical features and outcomes of ICU patients with pneumococcal pneumonia. The aims of this study were to provide epidemiological data and to determine risk factors of mortality in patients admitted to ICU for severe S. pneumoniae CAP. METHODS: We performed a retrospective review of two prospectively-acquired multicentre ICU databases (2001-2008). Patients admitted for management of severe pneumococcal CAP were enrolled if they met the 2001 American Thoracic Society criteria for severe pneumonia, had life-threatening organ failure and had a positive microbiological sample for S. pneumoniae. Patients with bronchitis, aspiration pneumonia or with non-pulmonary pneumococcal infections were excluded. RESULTS: Two hundred and twenty two patients were included, with a median SAPS 2 score reaching 47 [36-64]. Acute respiratory failure (n=154) and septic shock (n=54) were their most frequent causes of ICU admission. Septic shock occurred in 170 patients (77%) and mechanical ventilation was required in 186 patients (84%); renal replacement therapy was initiated in 70 patients (32%). Bacteremia was diagnosed in 101 patients. The prevalence of S. pneumoniae strains with decreased susceptibility to penicillin was 39.7%. Although antibiotherapy was adequate in 92.3% of cases, hospital mortality reached 28.8%. In multivariate analysis, independent risk factors for mortality were age [OR 1.05 (95% CI: 1.02-1.08)], male sex [OR 2.83 (95% CI: 1.16-6.91)] and renal replacement therapy [OR 3.78 (95% CI: 1.71-8.36)]. Co-morbidities, macrolide administration, concomitant bacteremia or penicillin susceptibility did not influence outcome. CONCLUSIONS: In ICU, mortality of pneumococcal CAP remains high despite adequate antimicrobial treatment. Baseline demographic data and renal replacement therapy have a major impact on adverse outcome.     

Elevated plasma levels of heparin-binding protein in intensive care unit patients with severe sepsis and septic shock

ABSTRACT: INTRODUCTION: Rapid detection of, and optimized treatment for, severe sepsis and septic shock is crucial for successful outcome. Heparin-binding protein (HBP), a potent inducer of increased vascular permeability, is a potentially useful biomarker for predicting outcome in patients with severe infections. Our aim was to study the systemic release and dynamics of HBP in the plasma of patients with severe sepsis and septic shock in the ICU. METHODS: A prospective study was conducted of two patient cohorts treated in the ICU at Karolinska University Hospital Huddinge in Sweden. A total of 179 patients was included, of whom 151 had sepsis (126 with septic shock and 25 patients with severe sepsis) and 28 a non-septic critical condition. Blood samples were collected at five time points during six days after admission. RESULTS: HBP levels were significantly higher in the sepsis group as compared to the control group. At admission to the ICU, a plasma HBP concentration of ≥15 ng/mL and/or a HBP (ng/mL)/white blood cell count (109/L) ratio of >2 was found in 87.2% and 50.0% of critically ill patients with sepsis and non-septic illness, respectively. A lactate level of >2.5 mmol/L was detected in 64.9% and 56.0% of the same patient groups. Both in the sepsis group (n = 151) and in the whole group (n = 179), plasma HBP concentrations at admission and in the last measured sample within the 144 hour study period were significantly higher among 28-day non-survivors as compared to survivors and in the sepsis group, an elevated HBP-level at baseline was associated with an increased case-fatality rate at 28 days. CONCLUSIONS: Plasma HBP levels were significantly higher in patients with severe sepsis or septic shock compared to patients with a non-septic illness in the ICU. HBP was associated with severity of disease and an elevated HBP at admission was associated with an increased risk of death. HBP that rises over time may identify patients with a deteriorating prognosis. Thus, repeated HBP measurement in the ICU may help monitor treatment and predict outcome in patients with severe infections.     

Impact of adequate empirical antibiotic therapy on the outcome of patients admitted to the intensive care unit with sepsis

OBJECTIVES: Our primary goal was to evaluate the impact on in-hospital mortality rate of adequate empirical antibiotic therapy, after controlling for confounding variables, in a cohort of patients admitted to the intensive care unit (ICU) with sepsis. The impact of adequate empirical antibiotic therapy on early (<3 days), 28-day, and 60-day mortality rates also was assessed. We determined the risk factors for inadequate empirical antibiotic therapy.DESIGN Prospective cohort study. SETTING: ICU of a tertiary hospital. PATIENTS: All the patients meeting criteria for sepsis at admission to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four hundred and six patients were included. Microbiological documentation of sepsis was obtained in 67% of the patients. At ICU admission, sepsis was present in 105 patients (25.9%), severe sepsis in 116 (28.6%), and septic shock in 185 (45.6%). By multivariate analysis, predictors of in-hospital mortality were Sepsis-related Organ Failure Assessment (SOFA) score at ICU admission (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.19-1.40), the increase in SOFA score over the first 3 days in the ICU (OR, 1.40; 95% CI, 1.19-1.65), respiratory failure within the first 24 hrs in the ICU (OR, 3.12; 95% CI, 1.54-6.33), and inadequate empirical antimicrobial therapy in patients with "nonsurgical sepsis" (OR, 8.14; 95% CI, 1.98-33.5), whereas adequate empirical antimicrobial therapy in "surgical sepsis" (OR, 0.37; 95% CI, 0.18-0.77) and urologic sepsis (OR, 0.14; 95% CI, 0.05-0.41) was a protective factor. Regarding early mortality (<3 days), factors associated with fatality were immunosuppression (OR, 4.57; 95% CI, 1.69-13.87), chronic cardiac failure (OR, 9.83; 95% CI, 1.98-48.69) renal failure within the first 24 hrs in the unit (OR, 8.63; 95% CI, 3.31-22.46), and respiratory failure within the first 24 hrs in the ICU (OR, 12.35; 95% CI, 4.50-33.85). Fungal infection (OR, 47.32; 95% CI, 5.56-200.97) and previous antibiotic therapy within the last month (OR, 2.23; 95% CI, 1.1-5.45) were independent variables related to administration of inadequate antibiotic therapy. CONCLUSIONS: In patients admitted to the ICU for sepsis, the adequacy of initial empirical antimicrobial treatment is crucial in terms of outcome, although early mortality rate was unaffected by the appropriateness of empirical antibiotic therapy.     

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.     

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.     

The influence of volume and intensive care unit organization on hospital mortality in patients admitted with severe sepsis: a retrospective multicentre cohort study

Introduction  

The aim of the study was to assess the influence of annual volume and factors related to intensive care unit (ICU) organization on in-hospital mortality among patients admitted to the ICU with severe sepsis.     

Arterial carbon dioxide tension and outcome in patients admitted to the intensive care unit after cardiac arrest

Background

Arterial carbon dioxide tension (PaCO₂) affects neuronal function and cerebral blood flow. However, its association with outcome in patients admitted to intensive care unit (ICU) after cardiac arrest (CA) has not been evaluated.

Methods and results

Observational cohort study using data from the Australian New Zealand (ANZ) Intensive Care Society Adult-Patient-Database (ANZICS-APD). Outcomes analyses were adjusted for illness severity, co-morbidities, hypothermia, treatment limitations, age, year of admission, glucose, source of admission, PaO₂ and propensity score.We studied 16,542 consecutive patients admitted to 125 ANZ ICUs after CA between 2000 and 2011. Using the APD-PaCO₂ (obtained within 24 h of ICU admission), 3010 (18.2%) were classified into the hypo- (PaCO₂ < 35 mmHg), 6705 (40.5%) into the normo- (35–45 mmHg) and 6827 (41.3%) into the hypercapnia (>45 mmHg) group. The hypocapnia group, compared with the normocapnia group, had a trend toward higher in-hospital mortality (OR 1.12 [95% CI 1.00–1.24, p = 0.04]), lower rate of discharge home (OR 0.81 [0.70–0.94, p < 0.01]) and higher likelihood of fulfilling composite adverse outcome of death and no discharge home (OR 1.23 [1.10–1.37, p < 0.001]). In contrast, the hypercapnia group had similar in-hospital mortality (OR 1.06 [0.97–1.15, p = 0.19]) but higher rate of discharge home among survivors (OR 1.16 [1.03–1.32, p = 0.01]) and similar likelihood of fulfilling the composite outcome (OR 0.97 [0.89–1.06, p = 0.52]). Cox-proportional hazards modelling supported these findings.

Conclusions

Hypo- and hypercapnia are common after ICU admission post-CA. Compared with normocapnia, hypocapnia was independently associated with worse clinical outcomes and hypercapnia a greater likelihood of discharge home among survivors.     

Aggressive fiuid management may be associated with disease progression in suspected sepsis patients admitted to the intensive care unit: a retrospective cohort study

<正>Sepsis is a lethal condition characterized by multiple organ dysfunction due to disrupted host responses to severe infections.^[1]Affected patients often have a Sequential Organ Failure Assessment (SOFA) score≥2.^[2]Patients with a SOFA score<2 and at least one of the following were considered as“suspected sepsis”:(1) quick SOFA (qSOFA) score≥2;(2) SOFA score=1;or (3) National Early Warning Score(NEWS) 4–6.^[3]Compared with studies on fiuid resuscitation...     

An audit of compliance with the sepsis resuscitation care bundle in patients admitted to A&E with severe sepsis or septic shock

Severe sepsis and septic shock are syndromes resulting in a systemic inflammatory response and the dysfunction of one or more organs following infection. The Surviving Sepsis Campaign is an international effort to reduce mortality in severe sepsis and septic shock by 25% by 2009 using a care bundle approach. It comprises evidenced-based interventions to be carried out within 6h of onset of sepsis. We conducted a prospective observational audit of 32 consecutive adult patients with severe sepsis or septic shock admitted via the A&E of a district general hospital. The compliance rate against each element, and overall compliance to the 6-h bundle were obtained. Patients' ages ranged from 55 to 75 years with 53% being male. Overall compliance was 19%. Arterial lactate was undertaken 100% of the time, and only just over half received an appropriate fluid challenge. Administration of an antibiotic was also very slow. Local recommendations include improvements to the track and trigger scoring system in A&E to improve recognition of sick patients, ensuring the doctor responsible for prescribing the antibiotic will administer it, and increasing awareness of the surviving sepsis campaign via education and training of all A&E staff. Given current evidence greater compliance to the care bundle may well improve patient outcomes for this client group.     

Incidence of severe sepsis and septic shock in German intensive care units: the prospective,multicentre INSEP study

Purpose

To estimate the incidence density, point prevalence and outcome of severe sepsis and septic shock in German intensive care units (ICUs).

Methods

In a prospective, multicentre, longitudinal observational study, all patients already on the ICU at 0:00 on 4 November 2013 and all patients admitted to a participating ICU between 0:00 on 4 November 2013 and 2359 hours on 1 December 2013 were included. The patients were followed up for the occurrence of severe sepsis or septic shock (SEPSIS-1 definitions) during their ICU stay.

Results

A total of 11,883 patients from 133 ICUs at 95 German hospitals were included in the study, of whom 1503 (12.6 %) were diagnosed with severe sepsis or septic shock. In 860 cases (57.2 %) the infections were of nosocomial origin. The point prevalence was 17.9 % (95 % CI 16.3–19.7).The calculated incidence rate of severe sepsis or septic shock was 11.64 (95 % CI 10.51–12.86) per 1000 ICU days. ICU mortality in patients with severe sepsis/septic shock was 34.3 %, compared with 6 % in those without sepsis. Total hospital mortality of patients with severe sepsis or septic shock was 40.4 %. Classification of the septic shock patients using the new SEPSIS-3 definitions showed higher ICU and hospital mortality (44.3 and 50.9 %).

Conclusions

Severe sepsis and septic shock continue to be a frequent syndrome associated with high hospital mortality. Nosocomial infections play a major role in the development of sepsis. This study presents a pragmatic, affordable and feasible method for the surveillance of sepsis epidemiology. Implementation of the new SEPSIS-3 definitions may have a major effect on future epidemiological data.

     

Short-term outcome among patients with leukemia and lymphoma admitted to a medical intensive care unit

We report here the short-term outcome of medical intensive care unit (MICU) admissions of patients with leukemia or lymphoma. We reviewed the charts of 29 such patients. Of 21 patients with acute leukemia admitted to the MICU, seven survived to leave the hospital; of eight patients with lymphoma, two survived to leave the hospital. The acute physiologic score (APS) (a system in which 0 to 4 points are given for the degree of deviation from normal for several organ systems) was used to score each patient on day 1 of their MICU stay. The APS for all patients with leukemia and lymphoma admitted to MICU was 28 +/- 11. The mortality was 69%, which is not significantly different from the predicted mortality of 56% for patients with the same APS but no underlying malignant disease. Among the survivors, young age and early stage of disease were predictors of favorable outcome.