Health-related quality of life in survivors of septic shock: 6-month follow-up from the ADRENAL trial

Health-associated quality of life impairment in people who inject drugs (PWID) after bloodstream infection

BACKGROUND

People who inject drugs (PWID) have high rates of bloodstream infections (BSI) with Staphylococcus aureus (SA) and group A streptococcus (GAS). Little is known about health-related quality of life outcomes after BSI.

METHODS

We performed a prospective pilot cohort study of patients with BSI due to SA or GAS. Health-related quality of life, anxiety, depression and cognitive function were assessed using validated tools (EQ5-5D-5L), Hospital Anxiety and Depression Score (HADS) and Montreal Cognitive Assessment (MOCA) at baseline, 28 days post-discharge and 6 months post-infection.

FINDINGS

66 patients were recruited over a 12-month period, including 17 PWID. For the whole cohort, global health rank improved from baseline to day 28 (median 40 to 60, p=0.002), with no significant improvement from day 28 to day 168 (median 60 to 75, p=0.161). At baseline, PWID had lower overall health-related quality of life than non-PWID (median 25 vs 45, p=0.229), persisting at day 28 (non-PWID median 65, PWID median 43, p=0.036) and day 168 (non-PWID median 75, PWID median 40, p=0.035). This difference was driven by worse scores in the EQ-5D-5L mental health component and HADS, with HADS scores being significantly impaired in PWID at baseline (p=0.001) and day 28 (p=0.007).

CONCLUSION

PWID have impaired health-related quality of life after SA and GAS BSI that persists for up to 6 months. Poor mental health is the major component of this, and further studies could clarify if this is a target for intervention.

Long-term mortality and health-related quality of life with lower versus higher oxygenation targets in intensive care unit patients with COVID-19 and severe hypoxaemia

PURPOSE

The aim of this study was to evaluate one-year outcomes of lower versus higher oxygenation targets in intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19) and severe hypoxaemia.

METHODS

We conducted pre-planned analyses of one-year mortality and health-related quality of life (HRQoL) in the Handling Oxygenation Targets in COVID-19 trial. The trial randomised 726 ICU patients with COVID-19 and hypoxaemia to partial pressure of arterial oxygen targets of 8 kPa (60 mmHg) versus 12 kPa (90 mmHg) during ICU stay up to 90 days, including readmissions. HRQoL was assessed using EuroQol visual analogue scale (EQ-VAS) and 5-level 5-dimension questionnaire (EQ-5D-5L). Outcomes were analysed in the intention-to-treat population. Non-survivors were assigned the worst possible score (zero), and multiple imputation was applied for missing EQ-VAS values.

RESULTS

We obtained one-year vital status for 691/726 (95.2%) of patients and HRQoL data for 642/726 (88.4%). At one year, 117/348 (33.6%) of patients in the lower-oxygenation group had died compared to 134/343 (39.1%) in the higher-oxygenation group (adjusted risk ratio: 0.85; 98.6% confidence interval (CI) 0.66-1.09; p = 0.11). Median EQ-VAS was 50 (interquartile range, 0-80) versus 40 (0-75) (adjusted mean difference: 4.8; 98.6% CI  - 2.2 to 11.9; p = 0.09) and EQ-5D-5L index values were 0.61 (0-0.81) in the lower-oxygenation group versus 0.43 (0-0.79) (p = 0.20) in the higher-oxygenation group, respectively.

CONCLUSION

Among adult ICU patients with COVID-19 and severe hypoxaemia, one-year mortality results were most compatible with benefit of the lower oxygenation target, which did not appear to result in more survivors with poor quality of life.

Factor Impacting Quality of Life Among Sepsis Survivors During and After Hospitalization: A Systematic Review of Current Empirical Evidence

Background

There remains a gap in understanding post-sepsis outcomes, particularly regarding the factors that influence the quality of life (QOL) among sepsis survivors during and after hospitalization.

Objective

To determine factors impacting QOL among sepsis survivors during and after hospitalization based on the evaluation and synthesis of current evidence.

Methods

This review encompassed studies published from January 2020 to December 2024, sourced from Scopus, PubMed, Medline, ScienceDirect, CINAHL Plus with Full Text, and Web of Science. The process of identifying, screening, excluding, and including articles followed the guidelines set by the Preferred Reporting Items for Systematic Reviews (PRISMA). Data synthesis for theme generation was conducted using the convergent integrated analysis framework as recommended by the Joanna Briggs Institute.

Results

A total of 1164 records were identified from the databases. After removing 130 duplicates, 1034 articles remained for screening based on their titles and abstracts according to the inclusion and exclusion criteria. At this stage, 1021 articles did not meet the criteria and were excluded, leaving 13 articles eligible for full-text screening. During this phase, 5 articles were excluded for various reasons, resulting in eight studies being included in the systematic review. Data synthesis of these studies revealed seven themes related to factors impacting QOL among sepsis survivors during and after hospitalization: 1) Physical Health Dimension, 2) Mental Health Dimension, 3) Treatment During Hospitalization, 4) Spiritual Dimension, 5) Social Support, 6) Mortality, and 7) Blood Biomarkers.

Conclusion

This systematic review provides valuable insights into the factors affecting the quality of life among sepsis survivors during and after hospitalization. These findings enhance the current knowledge base and offer clinicians, researchers, and policymakers actionable insights to improve outcomes and well-being for sepsis survivors.

Health-related quality of life and participation after inpatient rehabilitation of sepsis survivors with severe sequelae: a cohort study

OBJECTIVE

To describe health-related quality of life and participation after rehabilitation of severely affected sepsis survivors.

DESIGN

Cohort study.

SUBJECTS/PATIENTS

Patients with severe sequelae after sepsis treated in a multidisciplinary rehabilitation pathway were included.

METHODS

Patient characteristics at the time of diagnosis, and the outcome 3 months after discharge from rehabilitation are described. At that time, health-related quality of life, social participation, and the rate of living at home were measured.

RESULTS

Of the 498 patients enrolled, 100 severely impaired patients were transferred for a multidisciplinary rehabilitation approach. Fifty-five of them were followed up at 3 months. Descriptive and inference statistics showed that 69% were living at home with or without care. Health-related quality of life and participation scores were 0.64 ± 0.32 for the EQ-5D utility index and 54.98 ± 24.97 for the Reintegration of Normal Living Index. A multivariate regression model explaining health-related quality of life at 3 months included age, lower limb strength, and walking ability during rehabilitation (r2 = 0.5511). Participation at 3 months was explained by age, body mass index, lower limb strength, and duration of tracheal intubation (r2 = 0.6229).

CONCLUSION

Patients who have experienced serious sepsis with severe sequelae can achieve a moderate level of quality of life and participation within a multidisciplinary pathway.

Protocolized reduction of non-resuscitation fluids versus usual care in septic shock patients (REDUSE): a randomized multicentre feasibility trial

BACKGROUND/PURPOSE

Non-resuscitation fluids constitute the majority of fluid administered for septic shock patients in the intensive care unit (ICU). This multicentre, randomized, feasibility trial was conducted to test the hypothesis that a restrictive protocol targeting non-resuscitation fluids reduces the overall volume administered compared with usual care.

METHODS

Adults with septic shock in six Swedish ICUs were randomized within 12 h of ICU admission to receive either protocolized reduction of non-resuscitation fluids or usual care. The primary outcome was the total volume of fluid administered within three days of inclusion.

RESULTS

Median (IQR) total volume of fluid in the first three days, was 6008 ml (interquartile range [IQR] 3960-8123) in the restrictive fluid group (n = 44), and 9765 ml (IQR 6804-12,401) in the control group (n = 48); corresponding to a Hodges-Lehmann median difference of 3560 ml [95% confidence interval 1614-5302]; p < 0.001). Outcome data on all-cause mortality, days alive and free of mechanical ventilation and acute kidney injury or ischemic events in the ICU within 90 days of inclusion were recorded in 98/98 (100%), 95/98 (98%) and 95/98 (98%) of participants respectively. Cognition and health-related quality of life at six months were recorded in 39/52 (75%) and 41/52 (79%) of surviving participants, respectively. Ninety out of 134 patients (67%) of eligible patients were randomized, and 15/98 (15%) of the participants experienced at least one protocol violation.

CONCLUSION

Protocolized reduction of non-resuscitation fluids in patients with septic shock resulted in a large decrease in fluid administration compared with usual care. A trial using this design to test if reducing non-resuscitation fluids improves outcomes is feasible.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT05249088, 18 February 2022. https://clinicaltrials.gov/ct2/show/NCT05249088.

Clinical description and outcome of overall varicella-zoster virus-related organ dysfunctions admitted in intensive care units: the VAZOREA cohort study

BACKGROUND

Due to aging population and increasing part of immunocompromised patients, a raise in life-threatening organ damage related to VZV can be expected. Two retrospective studies were already conducted on VZV in ICU but focused on specific organ injury. Patients with high-risk of VZV disease still must be identified. The objective of this study was to report the clinical features and outcome of all life-threatening VZV manifestations requiring intensive care unit (ICU) admission. This retrospective cohort study was conducted in 26 French ICUs and included all adult patients with any life-threatening VZV-related event requiring ICU admission or occurring in ICU between 2010 and 2019.

RESULTS

One-hundred nineteen patients were included with a median SOFA score of 6. One hundred eight patients (90.8%) were admitted in ICU for VZV disease, leaving 11 (9.2%) with VZV disease occurring in ICU. Sixty-one patients (51.3%) were immunocompromised. Encephalitis was the most prominent organ involvement (55.5%), followed by pneumonia (44.5%) and hepatitis (9.2%). Fifty-four patients (45.4%) received norepinephrine, 72 (60.5% of the total cohort) needed invasive mechanical ventilation, and 31 (26.3%) received renal-replacement therapy. In-hospital mortality was 36.1% and was significantly associated with three independent risk factors by multivariable logistic regression: immunosuppression, VZV disease occurring in ICU and alcohol abuse. Hierarchical clustering on principal components revealed five phenotypically distinct clusters of patients: VZV-related pneumonia, mild encephalitis, severe encephalitis in solid organ transplant recipients, encephalitis in other immunocompromised hosts and VZV disease occurring in ICU. In-hospital mortality was highly different across phenotypes, ranging from zero to 75% (p < 0.001).

CONCLUSION

Overall, severe VZV manifestations are associated with high mortality in the ICU, which appears to be driven by immunosuppression status rather than any specific organ involvement. Deciphering the clinical phenotypes may help clinicians identify high-risk patients and assess prognosis.

Survivorship outcomes for critically ill patients in Australia and New Zealand: A scoping review

INTRODUCTION

Impairments after critical illness, termed the post-intensive care syndrome, are an increasing focus of research in Australasia. However, this research is yet to be cohesively synthesised and/or summarised.

OBJECTIVE

The aim of this scoping review was to explore patient outcomes of survivorship research, identify measures, methodologies, and designs, and explore the reported findings in Australasia.

INCLUSION CRITERIA

Studies reporting outcomes for adult survivors of critical illness from Australia and New Zealand in the following domains: physical, functional, psychosocial, cognitive, health-related quality of life (HRQoL), discharge destination, health care use, return to work, and ongoing symptoms/complications of critical illness.

METHODS

The Joanna Briggs Institute scoping review methodology framework was used. A protocol was published on the open science framework, and the search used Ovid MEDLINE, Scopus, ProQuest, and Google databases. Eligible studies were based on reports from Australia and New Zealand published in English between January 2000 and March 2022.

RESULTS

There were 68 studies identified with a wide array of study aims, methodology, and designs. The most common study type was nonexperimental cohort studies (n = 17), followed by studies using secondary analyses of other study types (n = 13). HRQoL was the most common domain of recovery reported. Overall, the identified studies reported that impairments and activity restrictions were associated with reduced HRQoL and reduced functional status was prevalent in survivors of critical illness. About 25% of 6-month survivors reported some form of disability. Usually, by 6 to12 months after critical illness, impairments had improved.

CONCLUSIONS

Reports of long-term outcomes for survivors of critical illness in Australia highlight that impairments and activity limitations are common and are associated with poor HRQoL. There was little New Zealand-specific research related to prevalence, impact, unmet needs, ongoing symptoms, complications from critical illness, and barriers to recovery.

The feasibility and acceptability of a physician-led ICU follow-up service: A prospective cohort study

BACKGROUND

Increased recognition of post-intensive care syndrome has led to widespread development of intensive care follow-up services internationally.

OBJECTIVE

The objective of this study was to determine the feasibility and acceptability of an intensive care unit (ICU) follow-up clinic in Australia for patients and their caregivers and to describe satisfaction with this service.

METHODS

This was a prospective cohort study in a mixed tertiary ICU in Australia. Eligible patients were adults admitted to the ICU for 7 days or more and/or ventilated for 48 h or more, as well as their primary caregiver. Patients and their primary caregivers were invited to attend a follow-up clinic 4-8 weeks after hospital discharge. The clinic appointment was attended by an ICU physician and nurse, with multidisciplinary support. Feasibility and acceptability were defined as the proportion of clinic attendance and frequency of interventions initiated at the clinic. Satisfaction was measured by a 5-point satisfaction survey (very dissatisfied to very satisfied). The burden of ongoing disease was reported via multiple validated instruments.

RESULTS

From April 2020-July 2021, 386 patients met the inclusion criteria. Only 146 patients were approached for consent due to site staffing limitations. Eighty-three patients and 32 caregivers consented to attend the clinic. Seventy percent (54/77) of patients attended scheduled appointments and 50% (16/32) of caregivers. For patients, 23 medical referrals were made, 8 patients had medication changes, and 10 patients were offered social work support. Satisfaction surveys were completed by 65% (35/54) of attending patients; 97% (34) patients reported either being 'very satisfied' or 'satisfied' with the service. All responding caregivers (10) were either 'very satisfied' or 'satisfied' with the clinic.

CONCLUSION

There were a large number of patients meeting the inclusion criteria to the ICU follow-up clinic, and clinic attendance was moderate for patients but lower for caregivers. Reported satisfaction with the service was high for both patients and their caregiver.

Accuracy of International Classification of Disease Coding Methods to Estimate Sepsis Epidemiology: A Scoping Review

PURPOSE

To provide an overview of various sepsis International Classification of Diseases (ICD) coding methods and their diagnostic accuracy.

METHODS

We undertook a systematic scoping review between 1991 and 2020 (search terms: sepsis, coding, and epidemiology) to include studies reporting the accuracy of a sepsis ICD coding method. Studies were grouped by ICD coding method, number of diagnostic accuracy parameters, ICD version, reference standard, design, country, setting, type of dataset and sepsis definition. ICD coding methods were categorised as explicit or implicit, with the explicit methods further divided into wide and narrow groups. Descriptive statistics were used to present data.

RESULTS

We analysed 17 studies, of which 16 (94.1%) used retrospective medical chart review as the reference standard for clinical sepsis, and eight (47.1%) used hospital administrative data to identify sepsis. There were 53 assessments of various ICD coding methods, with 32 (60.4%) of them being explicit and 21 (39.6%) implicit methods. The coding methods had a median sensitivity of <75% but a median specificity of >85%. However, a wide variation was noted in the diagnostic accuracy parameters of all ICD coding methods. Most of the studies showed high methodological quality.

CONCLUSION

None of the current ICD coding methods is optimal for identifying sepsis.

Does Differential Item Functioning Jeopardize the Comparability of Health-Related Quality of Life Assessment Between Patients and Proxies in Patients with Moderate-to-Severe Traumatic Brain Injury?

BACKGROUND

Health-related quality of life (HRQoL) is clearly recognized as a patient-important outcome in patients with traumatic brain injury (TBI). Patient-reported outcomes are therefore often used and supposed to be directly reported by the patients without interpretation of their responses by a physician or anyone else. However, patients with TBI are often unable to self-report because of physical and/or cognitive impairments. Thus, proxy-reported measures, e.g., family members, are often used on the patient's behalf. Yet, many studies have reported that proxy and patient ratings differ and are noncomparable. However, most studies usually do not account for other potential confounding factors that may be associated with HRQoL. In addition, patients and proxies can interpret some items of the patient-reported outcomes differently. As a result, item responses may not only reflect patients' HRQoL but also the respondent's (patient or proxy) own perception of the items. This phenomenon, called differential item functioning (DIF), can lead to substantial differences between patient-reported and proxy-reported measures and compromise their comparability, leading to highly biased HRQoL estimates. Using data from the prospective multicenter continuous hyperosmolar therapy in traumatic brain-injured patients study (240 patients with HRQoL measured with the Short Form-36 (SF-36)), we assessed the comparability of patients' and proxies' reports by evaluating the extent to which items perception differs (i.e., DIF) between patients and proxies after controlling for potential confounders.

METHODS

Items at risk of DIF adjusting for confounders were examined on the items of the role physical and role emotional domains of the SF-36.

RESULTS

Differential item functioning was evidenced in three out of the four items of the role physical domain measuring role limitations due to physical health problems and in one out of the three items of the role emotional domain measuring role limitations due to personal or emotional problems. Overall, despite an expected similar level of role limitations between patients who were able to respond and those for whom proxies responded, proxies tend to give more pessimistic responses than patients in the case of major role limitations and more optimistic responses than patients in the case of minor limitations.

CONCLUSIONS

Patients with moderate-to-severe TBI and proxies seem to have different perceptions of the items measuring role limitations due to physical or emotional problems, questioning the comparability of patient and proxy data. Therefore, aggregating proxy and patient responses may bias HRQoL estimates and alter medical decision-making based on these patient-important outcomes.

Joint effect of human papillomavirus exposure, smoking and alcohol on risk of oral squamous cell carcinoma

BACKGROUND

Smoking, alcohol consumption, and human papillomavirus (HPV) infection are known risk factors for oral squamous cell carcinoma (OSCC) including SCC of oropharynx (SCCOP) and SCC of oral cavity (SCCOC). Researchers have examined each of these risk factors independently, but few have observed the potential risk of their interaction. This study investigated the interactions among these risk factors and risk of OSCC.

METHODS

Totally 377 patients with newly diagnosed SCCOP and SCCOC and 433 frequency-matched cancer-free controls by age and sex were included. Multivariable logistic regression was performed to calculate ORs and 95% CIs.

RESULTS

We found that overall OSCC risk was independently associated with smoking (adjusted OR(aOR), 1.4; 95%CI, 1.0-2.0), alcohol consumption (aOR, 1.6; 95%CI, 1.1-2.2), and HPV16 seropositivity (aOR, 3.3; 95%CI, 2.2-4.9), respectively. Additionally, we found that HPV16 seropositivity increased the risk of overall OSCC in ever-smokers (aOR, 6.8; 95%CI, 3.4-13.4) and ever-drinkers (aOR, 4.8; 95%CI, 2.9-8.0), while HPV16-seronegative ever-smokers and ever-drinkers had less than a twofold increase in risk of overall OSCC (aORs, 1.2; 95%CI, 0.8-1.7 and 1.8; 95%CI, 1.2-2.7, respectively). Furthermore, the increased risk was particularly high for SCCOP in HPV16-seropositive ever-smokers (aOR, 13.0; 95%CI, 6.0-27.7) and in HPV16-seropositive ever-drinkers (aOR, 10.8; 95%CI, 5.8-20.1), while the similar increased risk was not found in SCCOC.

CONCLUSION

These results suggest a strong combined effect of HPV16 exposure, smoking, and alcohol on overall OSCC, which may indicate a strong interaction between HPV16 infection and smoking and alcohol consumption, particularly for SCCOP.

Quality of life and mortality in older adults with sepsis after one-year follow up: A prospective cohort study demonstrating the significant impact of frailty

BACKGROUND

Survivors of sepsis often develop chronic critical illness after the inflammatory stage, resulting in death or hospital readmission. The long-term prognosis of older patients with sepsis and the associated factors, particularly frailty, are not well studied.

OBJECTIVES

To investigate the effect of frailty on the quality of life (QoL) and mortality in older patients after one year of sepsis diagnosis.

METHODS

This prospective study included patients admitted to a specialized geriatric intensive care unit between May 2018 and April 2019. Patients were grouped according to the Clinical Frailty Scale as severely frail, mildly to moderately frail, and non-frail/vulnerable. The primary outcome was QoL one year after sepsis diagnosis, measured using the European QoL 5-Dimension (EQ-5D) and 12-item Short Form. The secondary outcome was one-year survival.

RESULTS

Of the 211 participants, 75 (35.5%) completed the QoL surveys. Of them, 37 (49.3%) did not return to their baseline QoL one year after sepsis diagnosis. The rate of reported mobility problems (a dimension of the EQ-5D) increased by 100% during the year. Additionally, survivors in the severely frail group exhibited poorer QoL at one year than those in the mildly to moderately frail and non-frail/vulnerable groups. The one-year mortality in the severely frail group was 75.9%, with an adjusted hazard ratio of 1.70 (95% confidence interval, 1.02-2.82, p = 0.041).

CONCLUSIONS

Frailty significantly impacts the one-year prognosis in older patients with sepsis. This research highlights the need for frailty management and physical rehabilitation in frail older patients at risk of poor prognosis, with implications for improving transitional and post-acute care services.

Using the EQ-5D-5L to investigate quality-of-life impacts of disease-modifying therapy policies for people with multiple sclerosis (MS) in New Zealand

BACKGROUND

Health state utilities (HSU) are a health-related quality-of-life (HRQoL) input for cost-utility analyses used for resource allocation decisions, including medication reimbursement. New Zealand (NZ) guidelines recommend the EQ-5D instruments; however, the EQ-5D-5L may not sufficiently capture psychosocial health. We evaluated HRQoL among people with multiple sclerosis (MS) in NZ using the EQ-5D-5L and assessed the instrument's discriminatory sensitivity for a NZ MS cohort.

METHODS

Participants were recruited from the NZ MS Prevalence Study. Participants self-completed a 45-min online survey that included the EQ-5D-5L/EQ-VAS. Disability severity was classified using the Expanded Disability Status Scale (EDSS) to categorise participant disability as mild (EDSS: 0-3.5), moderate (EDSS: 4.0-6.0) and severe (EDSS: 6.5-9.5). Anxiety/depression were also measured using the Hospital Anxiety and Depression Score (HADS). In the absence of an EQ-5D-5L NZ tariff, HSUs were derived using an Australian tariff. We evaluated associations between HSUs and participant characteristics with linear regression models.

RESULTS

254 participants entered the study. Mean age was 55.2 years, 79.5% were female. Mean (SD) EQ-5D-5L HSU was 0.58 (0.33). Mean (SD) HSUs for disability categories were: mild 0.80 ± 0.17, moderate 0.57 ± 0.21 and severe 0.14 ± 0.32. Twelve percent reported HSU = 1.0 (i.e., no problems in any domain). Participants who had never used a disease-modifying therapy reported a lower mean HSU. Multivariable modelling found that the HADS anxiety score was not associated with EQ-5D-5L.

CONCLUSIONS

HRQoL for people with MS in NZ was lower than comparable countries, including Australia. We suggest a comparison with other generic tools that may have improved sensitivity to mental health.

Six-Month Quality of Life in COVID-19 Intensive Care Unit Survivors

OBJECTIVES

Because there is increasing evidence of serious deterioration in long-term quality of life (QoL) in coronavirus 2019 (COVID-19) intensive care unit (ICU) survivors, the authors identified predictors of poor quality of life in these patients.

DESIGN

Prospective cohort study.

SETTING

Research hospital repurposed into a COVID-19 center.

PARTICIPANTS

Consecutive patients admitted in COVID-19 ICUs between March and June 2020.

INTERVENTIONS

An SF-36 questionnaire, which included physical and mental items, was used six months after patient's discharge.

MEASUREMENTS AND MAIN RESULTS

A total of 403 patients were managed in the ICU, with a hospital mortality of 181 of 403 (44.9%), and 16 (4.0%) patients died within six months. Among the 125 questionnaire responders, only 32.0% and 52% had a normal quality of life in terms of the physical and mental component of health. Multivariate analysis identified low-molecular-weight heparin treatment in the ICU as the only modifiable factor associated with an increase in physical component of QoL odds ratio (OR) 3.341 (95% confidence interval 1.298-8.599), p = 0.012, and age ≥52 years OR 0.223 and female sex OR 0.321 were significantly associated with a decrease in the physical component. Medical history of cerebrovascular insufficiency was significantly associated with a decrease in mental component of QoL OR 0.125, and the only factor associated with an increase in the mental health component was body mass index ≥27.6 kg/m² OR 7.466.

CONCLUSIONS

In COVID-19 ICU survivors the authors identified treatment with low- molecular-weight heparin as a predictor of improved physical component of QoL at 6 months.

Long-term outcomes of dexamethasone 12 mg versus 6 mg in patients with COVID-19 and severe hypoxaemia

PURPOSE

We assessed long-term outcomes of dexamethasone 12 mg versus 6 mg given daily for up to 10 days in patients with coronavirus disease 2019 (COVID-19) and severe hypoxaemia.

METHODS

We assessed 180-day mortality and health-related quality of life (HRQoL) using EuroQoL (EQ)-5D-5L index values and EQ visual analogue scale (VAS) in the international, stratified, blinded COVID STEROID 2 trial, which randomised 1000 adults with confirmed COVID-19 receiving at least 10 L/min of oxygen or mechanical ventilation in 26 hospitals in Europe and India. In the HRQoL analyses, higher values indicated better outcomes, and deceased patients were given a score of zero.

RESULTS

We obtained vital status at 180 days for 963 of 982 patients (98.1%) in the intention-to-treat population, EQ-5D-5L index value data for 922 (93.9%) and EQ VAS data for 924 (94.1%). At 180 days, 164 of 486 patients (33.7%) had died in the 12 mg group versus 184 of 477 (38.6%) in the 6 mg group [adjusted risk difference - 4.3%; 99% confidence interval (CI) - 11.7-3.0; relative risk 0.89; 0.72-1.09; P = 0.13]. The adjusted mean differences between the 12 mg and the 6 mg groups in EQ-5D-5L index values were 0.06 (99% CI - 0.01 to 0.12; P = 0.10) and in EQ VAS scores 4 (- 3 to 10; P = 0.22).

CONCLUSION

Among patients with COVID-19 and severe hypoxaemia, dexamethasone 12 mg compared with 6 mg did not result in statistically significant improvements in mortality or HRQoL at 180 days, but the results were most compatible with benefit from the higher dose.

Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)-protocol for a multicenter, randomized, clinical, proof-of-concept trial

BACKGROUND

Intravenous fluids are often used in the treatment of sepsis. The better strategy regarding fluid volume is debated, but preliminary data in patients with septic shock or sepsis-related hypotension favor restrictive fluid administration. We describe the protocol and statistical analysis plan for the Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)-a multicenter, randomized clinical proof-of-concept trial. The aim of the REFACED Sepsis trial is to test if a restrictive intravenous fluid protocol in emergency department patients with sepsis without shock is feasible and decreases the intravenous fluid volume administered in comparison to standard care.

METHODS

This is an investigator-initiated, multicenter, randomized, parallel-group, open-labeled, feasibility trial investigating volumes of crystalloid fluid within 24 h in 124 patients with sepsis without shock enrolled at three emergency departments in the Central Denmark Region. Patients are allocated to two different intravenous fluid regimens: a restrictive approach using four trigger criteria for fluid administration vs. standard care. The primary, feasibility outcome is total intravenous, crystalloid fluid volume within 24 h, and key secondary outcomes include protocol violations, total fluids (intravenous and oral) within 24 h, and serious adverse reactions and suspected unexpected serious adverse reactions. Status: The trial started in November 2021, and the last patient is anticipated to be included in January 2022.

DISCUSSION

Sepsis is very common in emergency department patients and fluid administration is very frequently administered in these patients. However, the evidence to guide fluid administration is very sparse. This feasibility trial will be the foundation for a potential future large-scale trial investigating restrictive vs. standard fluid administration in patients with sepsis.

TRIAL REGISTRATION

EudraCT number: 2021-000224-35 (date: 2021 May 03), ClinicalTrials.gov number: NCT05076435 (date: 2021 October 13), Committee on Health Research Ethics - Central Denmark Region: 1-10-72-163-21 (date: 2021 June 28).

Outcomes following severe septic shock in a cohort of Aboriginal and Torres Strait Islander people: a nested cohort study from the ADRENAL trial

Objective: To describe the pattern of acute illness and 6-month mortality and health-related quality-of-life outcomes for a cohort of Aboriginal and Torres Strait Islander patients presenting with septic shock. Design: Nested cohort study of Aboriginal and Torres Strait Islander participants recruited to a large randomised controlled trial of corticosteroid treatment in patients with septic shock. Setting: Royal Darwin Hospital, Northern Territory. Participants: All Aboriginal and Torres Strait Islander patients recruited to the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) trial at Royal Darwin Hospital were compared with a non-Indigenous cohort drawn from the same site, and a cohort matched for age, sex and severity of disease. Main outcome measures: Mortality at 90 days and 6 months, time to shock resolution, mechanical ventilation requirement, renal replacement therapy requirement, and five-domain, five-level EuroQol questionnaire (EQ-5D-5L) score at 6 months. Results: Aboriginal and Torres Strait Islander patients had significantly reduced risk of death at 90 days when compared with non-Indigenous patients recruited to ADRENAL at Royal Darwin Hospital (12/60 v 23/62; adjusted odds ratio, 0.40 [95% CI, 0.17 to 0.94]) which was robust to additional adjustment for baseline covariates (odds ratio, 0.35 [95% CI, 0.14 to 0.90]). When compared with the matched population drawn from the broader ADRENAL cohort, there was no significant difference in 90-day mortality (12/60 v 16/61; adjusted odds ratio, 1.43 [95% CI, 0.60 to 3.39]; P = 0.42). Only nine Aboriginal and Torres Strait Islander patients provided 6-month health-related quality-of-life data. Conclusions: Aboriginal and Torres Strait Islander patients had reduced risk of death at 90 days when compared with non- Indigenous patients recruited to the ADRENAL trial at Royal Darwin Hospital, which was robust to adjustment for covariates, but similar outcomes when compared with a cohort matched for age, sex and severity of disease.

Long-term mortality and health-related quality of life of lower versus higher oxygenation targets in ICU patients with severe hypoxaemia

PURPOSE

We assessed outcomes after 1 year of lower versus higher oxygenation targets in intensive care unit (ICU) patients with severe hypoxaemia.

METHODS

Pre-planned analyses evaluating 1-year mortality and health-related quality-of-life (HRQoL) outcomes in the previously published Handling Oxygenation Targets in the ICU trial which randomised 2928 adults with acute hypoxaemia to targets of arterial oxygen of 8 kPa or 12 kPa throughout the ICU stay up to 90 days. One-year all-cause mortality was assessed in the intention-to-treat population. HRQoL was assessed using EuroQol 5 dimensions 5 levels (EQ-5D-5L) questionnaire and EQ visual analogue scale score (EQ-VAS), and analyses were conducted in both survivors only and the intention-to-treat population with assignment of the worst scores to deceased patients.

RESULTS

We obtained 1-year vital status for 2887/2928 (98.6%), and HRQoL for 2600/2928 (88.8%) of the trial population. One year after randomisation, 707/1442 patients (49%) in the lower oxygenation group vs. 704/1445 (48.7%) in the higher oxygenation group had died (adjusted risk ratio 1.00; 95% confidence interval 0.93-1.08, p = 0.92). In total, 1189/1476 (80.4%) 1-year survivors participated in HRQoL interviews: median EQ-VAS scores were 65 (interquartile range 50-80) in the lower oxygenation group versus 67 (50-80) in the higher oxygenation group (p = 0.98). None of the five EQ-5D-5L dimensions differed between groups.

CONCLUSION

Among adult ICU patients with severe hypoxaemia, a lower oxygenation target (8 kPa) did not improve survival or HRQoL at 1 year as compared to a higher oxygenation target (12 kPa).

Current opinion in management of septic shock due to Gram-negative bacteria

PURPOSE OF REVIEW

The COVID-19 pandemic has caused multiple challenges to ICUs, including an increased rate of secondary infections, mostly caused by Gram-negative micro-organisms. Worrying trends of resistance acquisition complicate this picture. We provide a review of the latest evidence to guide management of patients with septic shock because of Gram-negative bacteria.

RECENT FINDINGS

New laboratory techniques to detect pathogens and specific resistance patterns from the initial culture are available. Those may assist decreasing the time to adequate antimicrobial therapy and avoid unnecessary broad-spectrum antibiotic overuse. New antimicrobials, including β-lactam/β-lactamase inhibitor combinations, such as ceftolozane-tazobactam, imipenem-relebactam or meropenem-vaborbactam and cephalosporins, such as cefiderocol targeted to specific pathogens and resistance patterns are available for use in the clinical setting. Optimization of antibiotic dosing and delivery should follow pharmacokinetic and pharmacodynamic principles and wherever available therapeutic drug monitoring. Management of sepsis has brought capillary refill time back to the spotlight along with more reasoned fluid resuscitation and a moderate approach to timing of dialysis initiation.

SUMMARY

Novel rapid diagnostic tests and antimicrobials specifically targeted to Gram-negative pathogens are available and should be used within the principles of antimicrobial stewardship including de-escalation and short duration of antimicrobial therapy.

What Is the Role of Steroids for Septic Shock in 2021?

Corticosteroids have been used for decades in the adjunctive treatment of severe infections in intensive care. The most frequent scenario in intensive care is in septic shock, where low doses of glucocorticoids appear to restore vascular responsiveness to norepinephrine. There is a strong body of evidence suggesting that hydrocortisone reduces time on vasopressor, and may modulate the immune response. In this review, we explore the current evidence supporting the use of corticosteroids in septic shock, its benefits, and potential harms. In addition to landmark clinical trials, we will also describe new frontiers for the use of corticosteroids in septic shock which should be explored in future studies.

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

OBJECTIVE

The 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.

DESIGN

This 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.

SETTING

The study was conducted in New Zealand.

PARTICIPANTS AND INTERVENTION

Patients 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 MEASURES

Healthcare 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.

RESULTS

Of 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.

CONCLUSIONS

In New Zealand, adjunctive hydrocortisone did not reduce total healthcare expenditure or improve outcomes compared with placebo in patients with septic shock.

Effect of Ascorbic Acid, Corticosteroids, and Thiamine on Health-Related Quality of Life in Sepsis

Patients who experience sepsis often have long-term effects that may impact health-related quality of life. This study aimed to investigate whether the combination of ascorbic acid, corticosteroids, and thiamine compared with placebo improves health-related quality of life in patients with septic shock.

DESIGN

Secondary analysis of the Ascorbic Acid, Corticosteroids, and Thiamine in Sepsis randomized controlled trial (NCT03389555).

SETTING

Thirteen tertiary-care hospitals in the United States.

PATIENTS

Patients who were enrolled in Ascorbic Acid, Corticosteroids, and Thiamine in Sepsis, survived to 90 days post enrollment and were able to be contacted by telephone.

INTERVENTIONS

Patients were randomly assigned to parenteral ascorbic acid (1,500 mg), hydrocortisone (50 mg), and thiamine (100 mg) every 6 hours for 4 days or placebo.

MEASUREMENTS AND MAIN RESULTS

One hundred seventeen patients (59%) survived to 90 days and were administered the Short Form 36 questionnaire; of these, 72 (62%) completed the Short Form 36 (38 [53%] in the intervention group, 34 [47%] in placebo). Sixty-six (92%) completed all survey questions (36 [95%] in the intervention group, 30 [88%] in placebo). There was no significant difference in overall Short Form 36 score between intervention and placebo group (median score: 39.4 [interquartile range, 31.2-45.4] vs 43.2 [37.0-46.7], respectively, p = 0.18). We found no statistically significant difference between the two groups in any of the other health-related quality of life domains used.

CONCLUSIONS

We found no difference in the health-related quality of life in patients with septic shock treated with a combination of ascorbic acid, corticosteroids, and thiamine compared to placebo.