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Chang CW, Chen WY, Chen PY, Pan CH, Su SS, Tsai SY, Chen CC, Kuo CJ. Antipsychotic medications and severe sepsis in schizophrenia: A nested case-control study. Aust N Z J Psychiatry 2024; 58:892-903. [PMID: 38859553 DOI: 10.1177/00048674241258028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
BACKGROUND Sepsis constitutes a condition that involves life-threatening organ dysfunction induced by severe infection. This nested case-control study investigated risk factors for severe sepsis and whether antipsychotic use is associated with severe sepsis risk in patients with schizophrenia, a topic that has not been comprehensively explored in previous studies. METHODS We selected 39,432 patients with schizophrenia aged between 15 and 65 years from Taiwan's Psychiatric Inpatient Medical Claims database for the period 2000-2012. The case group comprised patients with severe sepsis after their first psychiatric admission (n = 1382). The case and control groups were randomly matched (1:4) by age, sex and first psychiatric admission (year) and finally comprised 1382 and 5528 individuals, respectively. We employed multivariable conditional logistic regression to identify (1) risk factors (physical illnesses and nonpsychiatric medications) and (2) antipsychotic-severe sepsis associations. RESULTS Higher numbers of psychiatric admissions and physical illnesses such as delirium, cerebrovascular disease and cancer were significantly associated with a higher risk of severe sepsis. Furthermore, severe sepsis was associated with the use of antithrombotic agents, systemic corticosteroids and agents targeting the renin-angiotensin system. Clozapine (adjusted risk ratio = 1.65) and quetiapine (adjusted risk ratio = 1.59) use were associated with an increased risk of severe sepsis. The use of more than one antipsychotic drug could further increase this risk. CONCLUSION Several physical illnesses and nonpsychiatric medications increase the risk of severe sepsis in patients with schizophrenia. Specifically, clozapine or quetiapine use significantly increased the risk of severe sepsis in these patients.
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Affiliation(s)
- Chun-Wei Chang
- Department of General Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, Taipei
| | - Wen-Yin Chen
- Department of General Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, Taipei
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City
| | - Po-Yu Chen
- Department of General Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, Taipei
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei
| | - Chun-Hung Pan
- Department of General Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, Taipei
- Department of Psychology, National Chengchi University, Taipei
| | - Sheng-Shiang Su
- Department of General Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, Taipei
| | - Shang-Ying Tsai
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei
- Psychiatric Research Center, Taipei Medical University Hospital, Taipei
| | - Chiao-Chicy Chen
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei
- Department of Psychiatry, Mackay Memorial Hospital, Taipei
- Department of Psychiatry, Mackay Medical College, Taipei
| | - Chian-Jue Kuo
- Department of General Psychiatry, Taipei City Psychiatric Center, Taipei City Hospital, Taipei
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei
- Psychiatric Research Center, Taipei Medical University Hospital, Taipei
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Inghammar M, Linder A, Lengquist M, Frigyesi A, Wetterberg H, Sundén-Cullberg J, Nilsson A. Long-term Mortality and Hospital Readmissions Among Survivors of Sepsis in Sweden: A Population-Based Cohort Study. Open Forum Infect Dis 2024; 11:ofae331. [PMID: 38962525 PMCID: PMC11221654 DOI: 10.1093/ofid/ofae331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/18/2024] [Indexed: 07/05/2024] Open
Abstract
Background Survivors of sepsis may experience long-term risk of increased morbidity and mortality, but estimations of cause-specific effects beyond 1 year after a sepsis episode are lacking. Method This nationwide population-based cohort study linked data from national registers to compare patients aged ≥18 years in Sweden admitted to an intensive care unit from 2008 to 2019 with severe community-acquired sepsis. Patients were identified through the Swedish Intensive Care Registry, and randomly selected population controls were matched for age, sex, calendar year, and county of residence. Confounding from comorbidities, health care use, and socioeconomic and demographic factors was accounted for by using entropy-balancing methods. Long-term mortality and readmission rates, total and cause specific, were compared for 20 313 patients with sepsis and 396 976 controls via Cox regression. Results During the total follow-up period, 56% of patients with sepsis died, as opposed to 26% of the weighted controls. The hazard ratio for all-cause mortality was attenuated with time but remained elevated in all periods: 3.0 (95% CI, 2.8-3.2) at 2 to 12 months after admission, 1.8 to 1.9 between 1 and 5 years, and 1.6 (95% CI, 1.5-1.8) at >5 years. The major causes of death and readmission among the sepsis cases were infectious diseases, cancer, and cardiovascular diseases. The hazard ratios were larger among those without underlying comorbidities. Conclusions Severe community-acquired sepsis was associated with substantial long-term effects beyond 1 year, as measured by mortality and rehospitalization. The cause-specific rates indicate the importance of underlying or undetected comorbidities while suggesting that survivors of sepsis may face increased long-term mortality and morbidity not explained by underlying health factors.
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Affiliation(s)
- Malin Inghammar
- Infection Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Infectious Diseases, Skåne University Hospital, Lund, Sweden
- Epidemiology, Population Studies and Infrastructures (EPI@LUND), Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Adam Linder
- Infection Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Infectious Diseases, Skåne University Hospital, Lund, Sweden
| | - Maria Lengquist
- Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Attila Frigyesi
- Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anesthesiology and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Hanna Wetterberg
- Infection Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Epidemiology, Population Studies and Infrastructures (EPI@LUND), Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Jonas Sundén-Cullberg
- Division of Infectious Diseases and Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Anton Nilsson
- Epidemiology, Population Studies and Infrastructures (EPI@LUND), Department of Laboratory Medicine, Lund University, Lund, Sweden
- Centre for Economic Demography, Lund University, Lund, Sweden
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Luijks ECN, van der Slikke EC, van Zanten ARH, Ter Maaten JC, Postma MJ, Hilderink HBM, Henning RH, Bouma HR. Societal costs of sepsis in the Netherlands. Crit Care 2024; 28:29. [PMID: 38254226 PMCID: PMC10802003 DOI: 10.1186/s13054-024-04816-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 01/18/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Sepsis is a life-threatening syndrome characterized by acute loss of organ function due to infection. Sepsis survivors are at risk for long-term comorbidities, have a reduced Quality of Life (QoL), and are prone to increased long-term mortality. The societal impact of sepsis includes its disease burden and indirect economic costs. However, these societal costs of sepsis are not fully understood. This study assessed sepsis's disease-related and indirect economic costs in the Netherlands. METHODS Sepsis prevalence, incidence, sepsis-related mortality, hospitalizations, life expectancy, QoL population norms, QoL reduction after sepsis, and healthcare use post-sepsis were obtained from previous literature and Statistics Netherlands. We used these data to estimate annual Quality-adjusted Life Years (QALYs), productivity loss, and increase in healthcare use post-sepsis. A sensitivity analysis was performed to analyze the burden and indirect economic costs of sepsis under alternative assumptions, resulting in a baseline, low, and high estimated burden. The results are presented as a baseline (low-high burden) estimate. RESULTS The annual disease burden of sepsis is approximately 57,304 (24,398-96,244; low-high burden) QALYs. Of this, mortality accounts for 26,898 (23,166-31,577) QALYs, QoL decrease post-sepsis accounts for 30,406 (1232-64,667) QALYs. The indirect economic burden, attributed to lost productivity and increased healthcare expenditure, is estimated at €416.1 (147.1-610.7) million utilizing the friction cost approach and €3.1 (0.4-5.7) billion using the human capital method. Cumulatively, the combined disease and indirect economic burdens range from €3.8 billion (friction method) to €6.5 billion (human capital method) annually within the Netherlands. CONCLUSIONS Sepsis and its complications pose a substantial disease and indirect economic burden to the Netherlands, with an indirect economic burden due to production loss that is potentially larger than the burden due to coronary heart disease or stroke. Our results emphasize the need for future studies to prevent sepsis, saving downstream costs and decreasing the economic burden.
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Affiliation(s)
- Erik C N Luijks
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Elisabeth C van der Slikke
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Arthur R H van Zanten
- Department of Intensive Care Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
- Division of Human Nutrition and Health, Wageningen University Research, Wageningen, The Netherlands
| | - Jan C Ter Maaten
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Maarten J Postma
- Department of Economics, Econometrics and Finance, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Department of Health Sciences, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Henk B M Hilderink
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Robert H Henning
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Hjalmar R Bouma
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
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Chung E, Chung KS, Leem AY, Woo A, Park MS, Kim YS, Lee SH. Impact of age on mortality and transfer to long-term care in patients in an intensive care unit. BMC Geriatr 2023; 23:839. [PMID: 38087191 PMCID: PMC10714659 DOI: 10.1186/s12877-023-04526-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND In the global trend of population aging, age is one of the significant factors to be considered in critically ill patients. However, the impact of age on clinical outcomes and long-term prognosis in this population varies across different studies. METHODS We conducted a retrospective cohort analysis for patients admitted to the medical intensive care unit (ICU) (30 beds) between January 2017 and December 2020 at the tertiary referral hospital in Korea. Patients were classified into three groups according to age: <65 years, old age (65-79 years), and very old age (≥ 80 years). Subsequently, enrolled patients were analyzed for acute mortality and long-term prognosis. RESULTS Among the 1584 patients, the median age was 67.0 (57.0-76.0) years, and 65.2% were male. Median ICU length of stay (LOS) (8, 9, and 10 days in < 65, 65-79, and ≥ 80 years, respectively; p = 0.006) and the proportion of patients who were transferred to long-term care hospital at the time of discharge (12.9% vs. 28.3% vs. 39.4%, respectively; p < 0.001) increased with age. Multivariable logistic analysis showed no significant difference in the 28-day mortality in the old age (adjusted odds ratio [aOR] 0.88; 95% confidence interval [CI] 0.65-1.17) and very old age (aOR 1.05; 95% CI 0.71-1.55) groups compared to that in patients with age < 65 years. However, the relevance of the proportion of ICU LOS ≥ 7 days and transfers to other hospitals after discharge increased with age. CONCLUSIONS Age did not affect acute mortality in critical illness patients. However, surviving older age groups required more long-term care facilities compared to patients younger than 65 years after acute management. These results indicate that in an aging society, the importance of not only acute management but also long-term care facilities may increase for critical illness patients.
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Affiliation(s)
- Eunki Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Kyung Soo Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ah Young Leem
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Ala Woo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Su Hwan Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Freeman-Sanderson A, Hemsley B, Thompson K, Rogers KD, Knowles S, Hammond NE. Communication functions of adult patients admitted to intensive care: A multicentre, binational point prevalence study. Aust Crit Care 2023; 36:1084-1089. [PMID: 37198003 DOI: 10.1016/j.aucc.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/30/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Patient communication is profoundly impacted during the intensive care unit (ICU) stay. While the impacts of altered communication are recognised, there is a paucity of data on the prevalence of communication attempts as well as modes utilised by patients and unit practices to manage communication function. OBJECTIVE The objectives of this study were to describe the prevalence and characteristics of observed communication attempts (nonverbal, verbal, and use of the staff call bell) in adult ICU patients and report on unit-level practices on communication management. METHODS A prospective, binational, cross-sectional point-prevalence study was conducted across 44 Australia and New Zealand adult ICUs. Data on communication attempts, modes, ICU-level guidelines, training, and resources were collected in June 2019. RESULTS Across 44 ICUs, 470 of 623 (75%) participants, including ventilated and nonventilated patients, were attempting to communicate on the study day. Of those invasively ventilated via an endotracheal tube for the entire study day, 42 of 172 (24%) were attempting to communicate and 39 of 45 (87%) patients with a tracheostomy were attempting to communicate. Across the cohort, the primary mode of communication was verbal communication, with 395 of 470 (84%) patients using speech; of those 371 of 395 (94%) spoke English and 24 of 395 (6%) spoke a language other than English. Participants attempting to communicate on the study day had a shorter length of stay (LOS), a mean difference of 3.8 days (95% confidence interval: 0.2; 5.1) shorter LOS in the ICU than those not attempting to communicate, and a mean difference 7.9 days (95% confidence interval: 3.1; 12.6) shorter LOS in hospital overall. Unit-level practices and supports were collected. Six of 44 (14%) ICUs had a protocol for communication management, training was available in 11 of 44 (25%) ICUs, and communication resources were available in 37 of 44 (84%) ICUs. CONCLUSION Three-quarters of patients admitted to the ICU were attempting to communicate on the study day, with multiple methods used to support verbal and nonverbal communication regardless of ventilation status. Guidance and training were absent from the majority of ICUs, indicating a need for development and implementation of policies, training, and resources.
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Affiliation(s)
- Amy Freeman-Sanderson
- Graduate School of Health, University of Technology, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia; Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Bronwyn Hemsley
- Graduate School of Health, University of Technology, Sydney, NSW, Australia; The University of Newcastle, NSW, Australia
| | - Kelly Thompson
- Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia; Nepean Blue Mountains Local Health District, Sydney, NSW, Australia
| | - Kris D Rogers
- Graduate School of Health, University of Technology, Sydney, NSW, Australia; Statistics Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Serena Knowles
- Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Naomi E Hammond
- Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
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Martínez-Casanova J, Esteve-Pitarch E, Colom-Codina H, Gumucio-Sanguino VD, Cobo-Sacristán S, Shaw E, Maisterra-Santos K, Sabater-Riera J, Pérez-Fernandez XL, Rigo-Bonnin R, Tubau-Quintano F, Carratalà J, Padullés-Zamora A. Predictive Factors of Piperacillin Exposure and the Impact on Target Attainment after Continuous Infusion Administration to Critically Ill Patients. Antibiotics (Basel) 2023; 12:antibiotics12030531. [PMID: 36978398 PMCID: PMC10044067 DOI: 10.3390/antibiotics12030531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/02/2023] [Accepted: 03/05/2023] [Indexed: 03/30/2023] Open
Abstract
Critically ill patients undergo significant pathophysiological changes that affect antibiotic pharmacokinetics. Piperacillin/tazobactam administered by continuous infusion (CI) improves pharmacokinetic/pharmacodynamic (PK/PD) target attainment. This study aimed to characterize piperacillin PK after CI administration of piperacillin/tazobactam in critically ill adult patients with preserved renal function and to determine the empirical optimal dosing regimen. A total of 218 piperacillin concentrations from 106 patients were simultaneously analyzed through the population PK approach. A two-compartment linear model best described the data. Creatinine clearance (CLCR) estimated by CKD-EPI was the covariate, the most predictive factor of piperacillin clearance (CL) interindividual variability. The mean (relative standard error) parameter estimates for the final model were: CL: 12.0 L/h (6.03%); central and peripheral compartment distribution volumes: 20.7 L (8.94%) and 62.4 L (50.80%), respectively; intercompartmental clearance: 4.8 L/h (26.4%). For the PK/PD target of 100% fT>1×MIC, 12 g of piperacillin provide a probability of target attainment > 90% for MIC < 16 mg/L, regardless of CLCR, but higher doses are needed for MIC = 16 mg/L when CLCR > 100 mL/min. For 100% fT>4×MIC, the highest dose (24 g/24 h) was not sufficient to ensure adequate exposure, except for MICs of 1 and 4 mg/L. Our model can be used as a support tool for initial dose guidance and during therapeutic drug monitoring.
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Affiliation(s)
- Javier Martínez-Casanova
- Pharmacy Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
- Farmacoteràpia, Farmacogenètica i Tecnologia Farmacèutica, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 Hospitalet de Llobregat, Spain
| | - Erika Esteve-Pitarch
- Pharmacy Department, Hospital Universitari de Tarragona Joan XXIII, 43005 Tarragona, Spain
| | - Helena Colom-Codina
- Farmacoteràpia, Farmacogenètica i Tecnologia Farmacèutica, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 Hospitalet de Llobregat, Spain
- Pharmacy and Pharmaceutical Technology and Physical Chemistry Department, Universitat de Barcelona, 08028 Barcelona, Spain
| | | | - Sara Cobo-Sacristán
- Pharmacy Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
- Farmacoteràpia, Farmacogenètica i Tecnologia Farmacèutica, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 Hospitalet de Llobregat, Spain
| | - Evelyn Shaw
- Infectious Diseases Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
- Epidemiologia de les Infeccions Bacterianes, Patologia Infecciosa i Transplantament, Institut d'Investigacio Biomedica de Bellvitge, IDIBELL, 08907 Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Kristel Maisterra-Santos
- Critical Care Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
| | - Joan Sabater-Riera
- Critical Care Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
| | - Xosé L Pérez-Fernandez
- Critical Care Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
| | - Raül Rigo-Bonnin
- Clinical Laboratory Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
| | - Fe Tubau-Quintano
- Department of Microbiology, Hospital Universitari de Bellvitge-IDIBELL, 08907 Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Jordi Carratalà
- Infectious Diseases Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Campus Ciencias de la Salud de Bellvitge, University of Barcelona, 08907 Hospitalet de Llobregat, Spain
| | - Ariadna Padullés-Zamora
- Pharmacy Department, Hospital Universitari de Bellvitge, 08907 Hospitalet de Llobregat, Spain
- Farmacoteràpia, Farmacogenètica i Tecnologia Farmacèutica, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, 08907 Hospitalet de Llobregat, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
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Maegele M, Aletti F, Efron PA, Relja B, Orfanos SE. NEW INSIGHTS INTO THE PATHOPHYSIOLOGY OF TRAUMA AND HEMORRHAGE. Shock 2023; 59:6-9. [PMID: 36867756 DOI: 10.1097/shk.0000000000001954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
ABSTRACT Circulatory shock from trauma and hemorrhage remains a clinical challenge with mortality still high within the first hours after impact. It represents a complex disease involving the impairment of a number of physiological systems and organs and the interaction of different pathological mechanisms. Multiple external and patient-specific factors may further modulate and complicate the clinical course. Recently, novel targets and models with complex multiscale interaction of data from different sources have been identified which offer new windows of opportunity. Future works needs to consider patient-specific conditions and outcomes to mount shock research onto the next higher level of precision and personalized medicine.
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Affiliation(s)
- Marc Maegele
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Institute for Research in Operative Medicine, University Witten-Herdecke, Cologne, Germany
| | - Federico Aletti
- Instituto de Ciência e Tecnologia, Universidade Federal de São Paulo, São José dos Campos, Brazil
| | - Philip A Efron
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Laboratory of Inflammation Biology and Surgical Science, UF Health Critical Care Organization, Florida
| | - Borna Relja
- Department of Radiology and Nuclear Medicine, Experimental Radiology, Otto-von-Guericke University, Magdeburg, Germany
| | - Stylianos E Orfanos
- 1st Department of Critical Care Medicine, National and Kapodistrian University of Athens, Medical School, Greece
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Cost of postoperative sepsis in Vietnam. Sci Rep 2022; 12:4876. [PMID: 35319021 PMCID: PMC8941147 DOI: 10.1038/s41598-022-08881-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 03/08/2022] [Indexed: 11/09/2022] Open
Abstract
Despite improvements in medical care, the burden of sepsis remains high. In this study, we evaluated the incremental cost associated with postoperative sepsis and the impact of postoperative sepsis on clinical outcomes among surgical patients in Vietnam. We used the national database that contained 1,241,893 surgical patients undergoing seven types of surgery. We controlled the balance between the groups of patients using propensity score matching method. Generalized gamma regression and logistic regression were utilized to estimate incremental cost, readmission, and reexamination associated with postoperative sepsis. The average incremental cost associated with postoperative sepsis was 724.1 USD (95% CI 553.7-891.7) for the 30 days after surgery, which is equivalent to 28.2% of the per capita GDP in Vietnam in 2018. The highest incremental cost was found in patients undergoing cardiothoracic surgery, at 2,897 USD (95% CI 530.7-5263.2). Postoperative sepsis increased patient odds of readmission (OR = 6.40; 95% CI 6.06-6.76), reexamination (OR = 1.67; 95% CI 1.58-1.76), and also associated with 4.9 days longer of hospital length of stay among surgical patients. Creating appropriate prevention strategies for postoperative sepsis is extremely important, not only to improve the quality of health care but also to save health financial resources each year.
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Schaefer K, Austhof E, Boyd K, Armstrong A, Hoffman S, Pogreba-Brown K. Septicemia Due to Listeria monocytogenes Infection: A Systematic Review and Meta-Analysis. Foodborne Pathog Dis 2021; 19:104-114. [PMID: 34883025 DOI: 10.1089/fpd.2021.0046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Listeriosis is a rare bacterial infection associated with foodborne illness that can result in septicemia, a serious acute outcome. Sepsis is responsible for one in three deaths during hospitalization. The objective of this study was to conduct a systematic review and meta-analysis to estimate the proportion of Listeria monocytogenes infections resulting in septicemia. PubMed, Embase, Scopus, and Web of Science were searched from January 1, 2000, to April 1, 2018, for epidemiological studies that assessed studies focusing on L. monocytogenes infections with the outcome of septicemia. Articles in English, Spanish, and Portuguese using case-control, cohort, or outbreak studies reporting measures of association between L. monocytogenes and septicemia were included. Bias and heterogeneity were assessed using univariate meta-regression for region, sample size, study design, and report method. Nineteen articles were eligible for inclusion post-screening, the majority of which were conducted in Europe (n = 15); utilized a retrospective cohort design (n = 16); and collected data via routine or laboratory surveillance methods (n = 10). Prevalence of sepsis ranged from 4.2% to 100% among study populations of 6 to 1374 individuals. Overall, the proportion of listeriosis cases that developed sepsis was 46% (95% confidence interval [CI] 31.0-61.0%); for neonatal cases, 21.3% (95% CI 11.0-31.6%); and for maternal and neonatal cases, 18.8% (95% CI 10.7-26.8%). The heterogeneity was high for overall and group meta-analyses, but it could not be explained by the subanalyses for the overall proportion, whereas for neonatal, and neonatal and maternal cases combined, China had a significantly lower proportion than Europe and the United States. Septicemia following L. monocytogenes infection is a severe acute complication with 31-61% rate found overall; however, greater delineation of demographic data is needed to determine important risk factors. Future research should aim to address the gaps in knowledge in the long-term outcomes of sepsis from L. monocytogenes infection, and whether these outcomes differ from those due to other infections.
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Affiliation(s)
- Kenzie Schaefer
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona, USA
| | - Erika Austhof
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona, USA
| | - Kylie Boyd
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona, USA
| | - Alexandra Armstrong
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona, USA
| | - Sandra Hoffman
- U.S. Department of Agriculture, Economic Research Service, Washington, District of Columbia, USA
| | - Kristen Pogreba-Brown
- Department of Epidemiology and Biostatistics, University of Arizona, Tucson, Arizona, USA
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10
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Kowalkowski M, Eaton T, McWilliams A, Tapp H, Rios A, Murphy S, Burns R, Gutnik B, O'Hare K, McCurdy L, Dulin M, Blanchette C, Chou SH, Halpern S, Angus DC, Taylor SP. Protocol for a two-arm pragmatic stepped-wedge hybrid effectiveness-implementation trial evaluating Engagement and Collaborative Management to Proactively Advance Sepsis Survivorship (ENCOMPASS). BMC Health Serv Res 2021; 21:544. [PMID: 34078374 PMCID: PMC8170654 DOI: 10.1186/s12913-021-06521-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Sepsis survivors experience high morbidity and mortality, and healthcare systems lack effective strategies to address patient needs after hospital discharge. The Sepsis Transition and Recovery (STAR) program is a navigator-led, telehealth-based multicomponent strategy to provide proactive care coordination and monitoring of high-risk patients using evidence-driven, post-sepsis care tasks. The purpose of this study is to evaluate the effectiveness of STAR to improve outcomes for sepsis patients and to examine contextual factors that influence STAR implementation. METHODS This study uses a hybrid type I effectiveness-implementation design to concurrently test clinical effectiveness and gather implementation data. The effectiveness evaluation is a two-arm, pragmatic, stepped-wedge cluster randomized controlled trial at eight hospitals in North Carolina comparing clinical outcomes between sepsis survivors who receive Usual Care versus care delivered through STAR. Each hospital begins in a Usual Care control phase and transitions to STAR in a randomly assigned sequence (one every 4 months). During months that a hospital is allocated to Usual Care, all eligible patients will receive usual care. Once a hospital transitions to STAR, all eligible patients will receive STAR during their hospitalization and extending through 90 days from discharge. STAR includes centrally located nurse navigators using telephonic counseling and electronic health record-based support to facilitate best-practice post-sepsis care strategies including post-discharge review of medications, evaluation for new impairments or symptoms, monitoring existing comorbidities, and palliative care referral when appropriate. Adults admitted with suspected sepsis, defined by clinical criteria for infection and organ failure, are included. Planned enrollment is 4032 patients during a 36-month period. The primary effectiveness outcome is the composite of all-cause hospital readmission or mortality within 90 days of discharge. A mixed-methods implementation evaluation will be conducted before, during, and after STAR implementation. DISCUSSION This pragmatic evaluation will test the effectiveness of STAR to reduce combined hospital readmissions and mortality, while identifying key implementation factors. Results will provide practical information to advance understanding of how to integrate post-sepsis management across care settings and facilitate implementation, dissemination, and sustained utilization of best-practice post-sepsis management strategies in other heterogeneous healthcare delivery systems. TRIAL REGISTRATION NCT04495946 . Submitted July 7, 2020; Posted August 3, 2020.
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Affiliation(s)
- Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA.
| | - Tara Eaton
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA.,Department of Internal Medicine, Atrium Health, Charlotte, USA
| | - Hazel Tapp
- Department of Family Medicine, Atrium Health, Charlotte, USA
| | - Aleta Rios
- Ambulatory Care Management, Atrium Health, Charlotte, USA
| | | | - Ryan Burns
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Bella Gutnik
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | | | - Lewis McCurdy
- Division of Infectious Disease, Department of Internal Medicine, Atrium Health, Charlotte, USA
| | - Michael Dulin
- Academy for Population Health Innovation, University of North Carolina Charlotte & Mecklenburg County Public Health Department, Charlotte, USA.,Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA
| | - Christopher Blanchette
- Department of Public Health Sciences, University of North Carolina Charlotte, Charlotte, USA.,Health Economics and Outcomes Research Strategy, Novo Nordisk, Plainsboro Township, USA
| | - Shih-Hsiung Chou
- Center for Outcomes Research and Evaluation, Atrium Health, 1300 Scott Ave, Charlotte, NC, 28203, USA
| | - Scott Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, USA.,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA
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11
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Chronic Critical Illness and PICS Nutritional Strategies. J Clin Med 2021; 10:jcm10112294. [PMID: 34070395 PMCID: PMC8197535 DOI: 10.3390/jcm10112294] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 12/26/2022] Open
Abstract
The nutritional hallmark of chronic critical illness (CCI) after sepsis is persistent inflammation, immunosuppression, and catabolism syndrome (PICS), which results in global resistance to the anabolic effect of nutritional supplements. This ultimately leaves these patients in a downward phenotypic spiral characterized by cachexia with profound weakness, decreased capacity for rehabilitation, and immunosuppression with the propensity for sepsis recidivism. The persistent catabolism is driven by a pathologic low-grade inflammation with the inability to return to homeostasis and by ongoing increased energy expenditure. Better critical care support systems and advances in technology have led to increased intensive care unit (ICU) survival, but CCI due to PICS with poor long-term outcomes has emerged as a frequent phenotype among ICU sepsis survivors. Unfortunately, therapies to mitigate or reverse PICS-CCI are limited, and recent evidence supports that these patients fail to respond to early ICU evidence-based nutrition protocols. A lack of randomized controlled trials has limited strong recommendations for nutrition adjuncts in these patients. However, based on experience in other conditions characterized by a similar phenotype, immunonutrients aimed at counteracting inflammation, immunosuppression, and catabolism may be important for improving outcomes in PICS-CCI patients. This manuscript intends to review several immunonutrients as adjunctive therapies in treating PICS-CCI.
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12
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Apitzsch S, Larsson L, Larsson AK, Linder A. The physical and mental impact of surviving sepsis - a qualitative study of experiences and perceptions among a Swedish sample. Arch Public Health 2021; 79:66. [PMID: 33933171 PMCID: PMC8088073 DOI: 10.1186/s13690-021-00585-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/18/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Sepsis is a critical illness with high morbidity and mortality rates. Each year, sepsis affects about 48.9 million people all over the world. This study aims to illuminate how sepsis survivors experience sepsis and the impact of sepsis, as well as the health-related quality of life thereafter. METHODS An interview study with eight sepsis survivors was carried out in Sweden with an inductive qualitative method. The data were analyzed with content analysis. RESULTS Four themes were identified during the analysis; The experience of health care and being a sepsis patient, New circumstances´ impact on life, Family and social interactions, and The psychological impact on life. The lack of information about how sepsis can impact the survivors' lives and what to expect can lead to prolonged agony. The long recovery time comes as an unexpected and unpleasant surprise to those affected. Initially, the sepsis survivors are almost euphoric that they have survived, which can later lead to chock and trauma when they realize that they could have died. This insight needs to be processed in order to reach reconciliation with life after sepsis. CONCLUSION Sepsis has a huge impact on both physical and mental aspects of life. Many survivors suffer from persistent residual symptoms of varying degrees, to which they have to adapt. The sepsis survivors need individually adjusted information about the sepsis recovery trajectory, and what to expect during and after the hospital stay.
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Affiliation(s)
- Sabine Apitzsch
- The Emergency Department, Skåne University Hospital, Lund, Sweden
| | - Lotta Larsson
- Faculties of humanities and theology, Centre for Languages and Literature, Lund University, Lund, Sweden
| | - Anna-Karin Larsson
- Region Skåne, Department of Quality Management and Production, Lund/Malmö, Sweden
| | - Adam Linder
- Faculty of Medicine, Department of Clinical Sciences Lund, Division of Infection Medicine, Lund University, Lund, Sweden.
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13
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Bloodstream infections in the elderly: what is the real goal? Aging Clin Exp Res 2021; 33:1101-1112. [PMID: 31486996 DOI: 10.1007/s40520-019-01337-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/22/2019] [Indexed: 12/13/2022]
Abstract
Bloodstream infections (BSI) represent a serious bacterial infection with substantial morbidity and mortality. Population-based studies demonstrate an increased incidence, especially among elderly patients. Controversy exists regarding whether presentation of BSI are different in older patients compared to younger patients; our narrative review of the literature suggests that BSI in elderly patients would probably include one or more of the traditional symptoms/signs of fever, severe sepsis or septic shock, acute kidney injury, and/or leukocytosis. Sources of BSI in older adults are most commonly the urinary tract (more so than in younger adults) and the respiratory tract. Gram-negative bacteria are the most common isolates in the old (~ 40-60% of BSI); isolates from the elderly patient population show higher antibiotic resistance rates, with long-term care facilities serving as reservoirs for multidrug-resistant bacteria. BSI entail significantly higher rates of mortality in older age, both short and long term. Some of the risk factors for mortality are modifiable, such as the appropriateness of empirical antibiotic therapy and nosocomial acquisition of infection. Health-related quality of life issues regarding the elderly patient with BSI are not well addressed in the literature. Utilization of comprehensive geriatric assessment and comprehensive geriatric discharge planning need to be investigated further in this setting and might serve as key for improved results in this population. In this review, we address all these aspects of BSI in old patients with emphasis on future goals for management and research.
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14
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Lau VI, Xie F, Basmaji J, Cook DJ, Fowler R, Kiflen M, Sirotich E, Iansavichene A, Bagshaw SM, Wilcox ME, Lamontagne F, Ferguson N, Rochwerg B. Health-Related Quality-of-Life and Cost Utility Analyses in Critical Care: A Systematic Review. Crit Care Med 2021; 49:575-588. [PMID: 33591013 DOI: 10.1097/ccm.0000000000004851] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Cost utility analyses compare the costs and health outcome of interventions, with a denominator of quality-adjusted life year, a generic health utility measure combining both quality and quantity of life. Cost utility analyses are difficult to compare when methods are not standardized. It is unclear how cost utility analyses are measured/reported in critical care and what methodologic challenges cost utility analyses pose in this setting. This may lead to differences precluding cost utility analyses comparisons. Therefore, we performed a systematic review of cost utility analyses conducted in critical care. Our objectives were to understand: 1) methodologic characteristics, 2) how health-related quality-of-life was measured/reported, and 3) what costs were reported/measured. DESIGN Systematic review. DATA SOURCES We systematically searched for cost utility analyses in critical care in MEDLINE, Embase, American College of Physicians Journal Club, CENTRAL, Evidence-Based Medicine Reviews' selected subset of archived versions of UK National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, and American Economic Association electronic databases from inception to April 30, 2020. SETTING Adult ICUs. PATIENTS Adult critically ill patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 8,926 citations, 80 cost utility analyse studies were eligible. The time horizon most commonly reported was lifetime (59%). For health utility reporting, health-related quality-of-life was infrequently measured (29% reported), with only 5% of studies reporting baseline health-related quality-of-life. Indirect utility measures (generic, preference-based health utility measurement tools) were reported in 85% of studies (majority Euro-quality-of-life-5 Domains, 52%). Methods of estimating health-related quality-of-life were seldom used when the patient was incapacitated: imputation (19%), assigning fixed utilities for incapacitation (19%), and surrogates reporting on behalf of incapacitated patients (5%). For cost utility reporting transparency, separate incremental costs and quality-adjusted life years were both reported in only 76% of studies. Disaggregated quality-adjusted life years (reporting separate health utility and life years) were described in only 34% of studies. CONCLUSIONS We identified deficiencies which warrant recommendations (standardized measurement/reporting of resource use/unit costs/health-related quality-of-life/methodological preferences) for improved design, conduct, and reporting of future cost utility analyses in critical care.
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Affiliation(s)
- Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - John Basmaji
- Department of Medicine, Division of Critical Care Medicine, Western University, London, ON, Canada
| | - Deborah J Cook
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, ON, Canada
| | - Robert Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Ontario, ON, Canada
| | - Michel Kiflen
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Emily Sirotich
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | | | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Ontario, ON, Canada
| | - François Lamontagne
- Centre de Recherche du CHU de Sherbrooke, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Niall Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University Health Network, Ontario, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, ON, Canada
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15
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Schneidewind L. [Reducing mortality in adults with sepsis, severe sepsis, or septic shock: effectiveness and safety of procalcitonin]. Urologe A 2021; 60:624-627. [PMID: 33779788 DOI: 10.1007/s00120-021-01506-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Laila Schneidewind
- Urologische Klinik Und Poliklinik, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18055, Rostock, Deutschland. .,UroEvidence@DGU, Berlin, Deutschland.
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16
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Gritte RB, Souza-Siqueira T, Curi R, Machado MCC, Soriano FG. Why Septic Patients Remain Sick After Hospital Discharge? Front Immunol 2021; 11:605666. [PMID: 33658992 PMCID: PMC7917203 DOI: 10.3389/fimmu.2020.605666] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/29/2020] [Indexed: 12/29/2022] Open
Abstract
Sepsis is well known to cause a high patient death rate (up to 50%) during the intensive care unit (ICU) stay. In addition, sepsis survival patients also exhibit a very high death rate after hospital discharge compared to patients with any other disease. The addressed question is then: why septic patients remain ill after hospital discharge? The cellular and molecular mechanisms involved in the high rate of septic patient deaths are still unknown. We described herein the studies that investigated the percentage of septic patients that died after hospital discharge ranging from 90 days up to 5 years. We also reported the symptoms of septic patients after hospital discharge and the development of the recently called post-sepsis syndrome (PSS). The most common symptoms of the PSS are cognitive disabilities, physical functioning decline, difficulties in performing routine daily activities, and poor life quality. The PSS also associates with quite often reinfection and re-hospitalization. This condition is the cause of the high rate of death mentioned above. We reported the proportion of patients dying after hospital discharge up to 5 years of followed up and the PSS symptoms associated. The authors also discuss the possible cellular and metabolic reprogramming mechanisms related with the low survival of septic patients and the occurrence of PSS.
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Affiliation(s)
- Raquel Bragante Gritte
- Interdisciplinary Post-Graduate Program in Health Sciences, Cruzeiro do Sul University, Sao Paulo, Brazil
| | - Talita Souza-Siqueira
- Interdisciplinary Post-Graduate Program in Health Sciences, Cruzeiro do Sul University, Sao Paulo, Brazil
| | - Rui Curi
- Interdisciplinary Post-Graduate Program in Health Sciences, Cruzeiro do Sul University, Sao Paulo, Brazil.,Immunobiological Production Section, Bioindustrial Center, Butantan Institute, São Paulo, Brazil
| | | | - Francisco Garcia Soriano
- University Hospital, University of São Paulo, São Paulo, Brazil.,Internal Medicine Department, School of Medicine, University of São Paulo, São Paulo, Brazil
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17
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Schmidt K, Gensichen J, Fleischmann-Struzek C, Bahr V, Pausch C, Sakr Y, Reinhart K, Christian Vollmar H, Thiel P, Scherag A, Gantner* J, M. Brunkhorst* F. Long-Term Survival Following Sepsis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:775-782. [PMID: 33533711 PMCID: PMC7930463 DOI: 10.3238/arztebl.2020.0775] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 04/07/2020] [Accepted: 06/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND There have not yet been any prospective registry studies in Germany with active investigation of the long-term survival of patients with sepsis. METHODS The Jena Sepsis Registry (JSR) included all patients with a diagnosis of sepsis in the four intensive care units of Jena University Hospital from January 2011 to December 2015. Long-term survival 6-48 months after diagnosis was documented by asking the treating general practitioners. The survival times were studied with Kaplan-Meier estimators. Cox regressions were calculated to show associations between possible predictors and survival time. RESULTS 1975 patients with sepsis or septic shock were included. The mean time of observation was 730 days. For 96.4% of the queries to the general practitioners, information on long-term survival was available. Mortality in the intensive care unit was 34% (95% confidence interval [32; 37]), and in-hospital mortality was 45% [42; 47]. The overall mortality six months after diagnosis was 59% [57; 62], the overall mortality 48 months after diagnosis was 74% [72; 78]. Predictors of shorter survival were age, nosocomial origin of sepsis, diabetes, cerebrovascular disease, duration of stay in the intensive care unit, and renal replacement therapy. CONCLUSION The nearly 75% mortality four years after diagnosis indicates that changes are needed both in the acute treatment of patients with sepsis and in their multi-sector long-term care. The applicability of these findings may be limited by their having been obtained in a single center.
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Affiliation(s)
- Konrad Schmidt
- Center for Sepsis Control and Care (CSCC), Jena University Hospital:
- Institute of General Practice and Family Medicine, Jena University Hospital
- Institute of General Practice, Charité–Universitätsmedizin Berlin
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, Jena University Hospital
- Institute of General Practice and Family Medicine, Munich University Hospital, Ludwig-Maximilians-Universität München
| | | | - Viola Bahr
- Center for Clinical Studies, Jena University Hospital
| | - Christine Pausch
- Center for Sepsis Control and Care (CSCC), Jena University Hospital:
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), Leipzig University
| | - Yasser Sakr
- Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital
| | - Konrad Reinhart
- Center for Sepsis Control and Care (CSCC), Jena University Hospital:
- Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital
| | - Horst Christian Vollmar
- Institute of General Practice and Family Medicine, Jena University Hospital
- Institute of General Practice and Family Medicine, Ruhr-University Bochum
| | - Paul Thiel
- Center for Sepsis Control and Care (CSCC), Jena University Hospital:
- Institute of General Practice and Family Medicine, Jena University Hospital
| | - André Scherag
- Center for Sepsis Control and Care (CSCC), Jena University Hospital:
- Institute of Medical Statistics, Computer Science and Data Sciences, Jena University Hospital
| | - Julia Gantner*
- * Joint last authors
- Institute of Medical Statistics, Computer Science and Data Sciences, Jena University Hospital
| | - Frank M. Brunkhorst*
- Center for Sepsis Control and Care (CSCC), Jena University Hospital:
- Center for Clinical Studies, Jena University Hospital
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18
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Lv SJ, Zhang GH, Xia JM, Yu H, Zhao F. Early use of high-dose vitamin C is beneficial in treatment of sepsis. Ir J Med Sci 2020; 190:1183-1188. [PMID: 33094466 DOI: 10.1007/s11845-020-02394-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/07/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE Vitamin C has shown benefits in patients with sepsis in addition to standard therapy recently. However, further evidence is required to verify the efficacy of vitamin C in clinical practice. This study aimed to investigate the effect of adjunctive intravenous high-dose vitamin C treatment on hospital mortality in patients with sepsis. METHODS One hundred seventeen patients with sepsis in our department from June 2017 to May 2019 were randomly divided into two groups: the control group (56 cases) and the vitamin C group (61 cases). The control group was treated by the routine and basic therapy with intravenous drip of 5% dextrose and placebo (100 ml/time, 2 times/day), while the vitamin C group was administered intravenously by 3.0 g vitamin C dissolved into 5% dextrose (100 ml/time, 2 times/day) based on the control group. The mortality and efficacy were statistically analyzed and compared between the two groups. RESULTS The 28-day mortality differed significantly between the control group and the vitamin C group (42.97% vs. 27.93%) (p < 0.05). The changes in the sepsis-related organ failure assessment (ΔSOFA) scores at 72 h after ICU admission (4.2 vs. 2.1), the application time of vasoactive drugs (25.6 vs. 43.8), and the procalcitonin clearance (79.6% vs. 61.3%) differed significantly between groups (p < 0.05). CONCLUSION The early treatment of sepsis with intravenous high-dose vitamin C in combination with standard therapy showed a beneficial effect on sepsis, in terms of the reduced 28-day mortality, the decreased SOFA score, and the increased clearance rate of procalcitonin.
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Affiliation(s)
- Shi-Jin Lv
- Department of Emergency, Hangzhou Normal University Affiliated Hospital, Wenzhou Road 126, Hangzhou, 310015, Zhejiang, People's Republic of China
| | - Guo-Hu Zhang
- Department of Emergency, Hangzhou Normal University Affiliated Hospital, Wenzhou Road 126, Hangzhou, 310015, Zhejiang, People's Republic of China.
| | - Jin-Ming Xia
- Department of Emergency, Hangzhou Normal University Affiliated Hospital, Wenzhou Road 126, Hangzhou, 310015, Zhejiang, People's Republic of China
| | - Huan Yu
- Department of Emergency, Hangzhou Normal University Affiliated Hospital, Wenzhou Road 126, Hangzhou, 310015, Zhejiang, People's Republic of China
| | - Fei Zhao
- Department of Emergency, Hangzhou Normal University Affiliated Hospital, Wenzhou Road 126, Hangzhou, 310015, Zhejiang, People's Republic of China
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19
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Strandberg G, Walther S, Agvald Öhman C, Lipcsey M. Mortality after Severe Sepsis and Septic Shock in Swedish Intensive Care Units 2008-2016-A nationwide observational study. Acta Anaesthesiol Scand 2020; 64:967-975. [PMID: 32232853 DOI: 10.1111/aas.13587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 02/26/2020] [Accepted: 03/09/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recent studies have reported substantially decreased hospital mortality for sepsis, but data are scarcer on outcomes after hospital discharge. We studied mortality up to 1 year in Swedish intensive care unit (ICU) patients with and without sepsis. METHODS Demographic and medical data for all registered adult general ICU patients admitted between 01-01-2008 and 30-09-2016 were retrieved from the Swedish Intensive Care Registry and linked with the National Patient Register for comorbidity data and the Cause of Death Register for death dates. The population was divided in two cohorts; (a) Patients with a diagnosis of severe sepsis or septic shock and (b) All other ICU patients. Crude yearly mortality was calculated, and logistic regression was used to analyse predictors of mortality. RESULTS 28 886 sepsis and 221 941 nonsepsis ICU patients were identified. In the sepsis cohort, in 2008 unadjusted mortality was 32.6% at hospital discharge, 32.7% at 30 days, 39% at 90 days and 46.8% at 365 days. In 2016, mortality was 30.5% at hospital discharge, 31.9% at 30 days and 38% at 90 days. Mortality at 365 days was 45.3% in 2015. Corresponding nonsepsis mortality was 15.4%, 16.2%, 20% and 26% in 2008 and 15.6%, 17.1%, 20.7% and 26.7% in 2016/2015. No consistent decrease in odds of mortality was seen in the adjusted analysis. CONCLUSIONS Mortality in severe sepsis and septic shock is high, with more than one in three patients not surviving three months after ICU admission, and adjusted mortality has not decreased convincingly in Sweden 2008-2016. TRIAL REGISTRATION The study was registered prospectively, ClinicalTrials.gov ID: NCT03489447.
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Affiliation(s)
- Gunnar Strandberg
- Cardiothoracic Surgery and Anaesthesiology Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - Sten Walther
- Department of Cardiothoracic Anaesthesia and Intensive Care Division of Cardiovascular Medicine Department of Medical and Health Sciences Linköping University Hospital Linköping University Linköping Sweden
| | - Christina Agvald Öhman
- Anaesthesiology and Intensive Care Karolinska University Hospital Huddinge Stockholm Sweden
| | - Miklós Lipcsey
- Hedenstierna Laboratory, Anaesthesiology and Intensive Care Department of Surgical Sciences Uppsala University Uppsala Sweden
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Carey MR, Prescott HC, Iwashyna TJ, Wilson ME, Fagerlin A, Valley TS. Changes in Self-Rated Health After Sepsis in Older Adults: A Retrospective Cohort Study. Chest 2020; 158:1958-1966. [PMID: 32593804 DOI: 10.1016/j.chest.2020.05.606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/29/2020] [Accepted: 05/29/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND As more individuals survive sepsis, there is an urgent need to understand its effects on patient-reported outcomes. RESEARCH QUESTION What is the effect of sepsis on self-rated health, and what role, if any, does functional disability play in mediating this effect? STUDY DESIGN AND METHODS We conducted a survey- and administrative claims-based retrospective cohort study using the US Health and Retirement Study, a nationally representative cohort-based survey of older adults in the United States, from 2000 through 2016. We matched Medicare beneficiaries hospitalized with sepsis in 2000 to 2008 to nonhospitalized individuals. Self-rated health and functional disability were tracked biannually for 8 years. Differences in self-rated health between the cohorts were measured using mixed models with and without controlling for changes in functional disability. RESULTS Seven hundred fifty-eight individuals with sepsis were matched 1:1 to 758 nonhospitalized individuals, all aged 65 years and older. Among survivors, sepsis was associated with worse self-rated health in years 2 and 4 (adjusted absolute difference in self-rated health on a 5-point scale in year 2: -0.24 [95% CI, -0.38 to -0.10] and year 4: -0.17 [95% CI, -0.33 to -0.02]) but not in years 6 or 8. After accounting for changes in functional status, the association between sepsis and self-rated health was still present but reduced in year 2 (adjusted absolute difference in self-rated health, -0.18 [95% CI, -0.31 to -0.05]) and was not present in years 4, 6, or 8. INTERPRETATION Self-rated health worsened initially after sepsis but returned to the level of that of nonhospitalized control subjects by year 6. Mitigating sepsis-related functional disability may play a key role in improving self-rated health after sepsis.
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Affiliation(s)
| | - Hallie C Prescott
- Division of Pulmonary & Critical Care Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
| | - Theodore J Iwashyna
- Division of Pulmonary & Critical Care Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
| | - Michael E Wilson
- Division of Pulmonary & Critical Care Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN; Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT; VA Salt Lake City Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, UT
| | - Thomas S Valley
- Division of Pulmonary & Critical Care Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI; Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI.
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More Than We Bargained For: The "Dominating" Cost Effectiveness of Sepsis Quality Improvement? Crit Care Med 2020; 47:1464-1467. [PMID: 31524700 DOI: 10.1097/ccm.0000000000003944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
OBJECTIVES Cost-effectiveness analyses are increasingly used to aid decisions about resource allocation in healthcare; this practice is slow to translate into critical care. We sought to identify and summarize original cost-effectiveness studies presenting cost per quality-adjusted life year, incremental cost-effectiveness ratios, or cost per life-year ratios for treatments used in ICUs. DESIGN We conducted a systematic search of the English-language literature for cost-effectiveness analyses published from 1993 to 2018 in critical care. Study quality was assessed using the Drummond checklist. SETTING Critical care units. PATIENTS OR SUBJECTS Critical care patients. INTERVENTIONS Identified studies with cost-effectiveness analyses. MEASUREMENTS AND MAIN RESULTS We identified 97 studies published through 2018 with 156 cost-effectiveness ratios. Reported incremental cost-effectiveness ratios ranged from -$119,635 (hypothetical cohort of patients requiring either intermittent or continuous renal replacement therapy) to $876,539 (data from an acute renal failure study in which continuous renal replacement therapy was the most expensive therapy). Many studies reported favorable cost-effectiveness profiles (i.e., below $50,000 per life year or quality-adjusted life year). However, several therapies have since been proven harmful. Over 2 decades, relatively few cost-effectiveness studies in critical care have been published (average 4.6 studies per year). There has been a more recent trend toward using hypothetical cohorts and modeling scenarios without proven clinical data (2014-2018: 19/33 [58%]). CONCLUSIONS Despite critical care being a significant healthcare cost burden there remains a paucity of studies in the literature evaluating its cost effectiveness.
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Mankowski RT, Anton SD, Ghita GL, Brumback B, Cox MC, Mohr AM, Leeuwenburgh C, Moldawer LL, Efron PA, Brakenridge SC, Moore FA. Older Sepsis Survivors Suffer Persistent Disability Burden and Poor Long-Term Survival. J Am Geriatr Soc 2020; 68:1962-1969. [PMID: 32294254 DOI: 10.1111/jgs.16435] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/04/2020] [Accepted: 03/07/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Sepsis has been called a "disease of the elderly," and as in-hospital mortality has decreased, more sepsis survivors are progressing into poorly characterized long-term outcomes. The purpose of this study was to describe the current epidemiology of sepsis in older adults compared with middle-aged and young adults. DESIGN Prospective longitudinal study with young (≤45 years), middle-aged (46-64 years), and older (≥65 years) patient groups. SETTING University tertiary medical center. PARTICIPANTS A total of 328 adult surgical intensive care unit (ICU) sepsis patients. MEASUREMENTS Patients were characterized by (1) baseline demographics and predisposition, (2) septic event, (3) hospital outcomes and discharge disposition, (4) 12-month mortality, and (5) Zubrod Performance Status, physical function (Short Physical Performance Battery and handgrip strength), and cognitive function (Hopkins Verbal Learning Test, Controlled Oral Word Association, and Mini-Mental Status Examination) at 3-, 6-, and 12-month follow-up. Loss to follow-up was due to death (in 68), consent withdrawal (in 32), and illness and scheduling difficulties: month 3 (in 51), month 6 (in 29), and month 12 (in 20). RESULTS Compared with young and middle-aged patients, older patients had (1) significantly more comorbidities at presentation (eg, chronic renal disease 6% vs 12% vs 21%), intra-abdominal infections (14% vs 25% vs 37%), septic shock (12% vs 25% vs 36%), and organ dysfunctions; (2) higher 30-day mortality (6% vs 4% vs 17%) and fewer ICU-free days (median = 25 vs 23 vs 20); (3) more progression into chronic critical illness (22% vs 34% vs 42%) with higher poor disposition discharge to non-home destinations (19% vs 40% vs 62%); (4) worse 12-month mortality (11% vs 14% vs 33%); and (5) poorer Zubrod Performance Status and objectively measured physical and cognitive functions with only slight improvement over 12-month follow-up. CONCLUSION Compared with younger patients, older sepsis survivors suffer both a higher persistent disability burden and 12-month mortality.
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Affiliation(s)
- Robert T Mankowski
- Department of Aging and Geriatric Research, University of Florida, Gainesville, Florida, USA
| | - Stephen D Anton
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Gabriela L Ghita
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Babette Brumback
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA.,Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Michael C Cox
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Alicia M Mohr
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Christiaan Leeuwenburgh
- Department of Aging and Geriatric Research, University of Florida, Gainesville, Florida, USA
| | - Lyle L Moldawer
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Philip A Efron
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | | | - Frederick A Moore
- Department of Surgery, University of Florida, Gainesville, Florida, USA
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Quality of Life and 1-Year Survival in Patients With Early Septic Shock: Long-Term Follow-Up of the Australasian Resuscitation in Sepsis Evaluation Trial. Crit Care Med 2020; 47:765-773. [PMID: 30985391 DOI: 10.1097/ccm.0000000000003762] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To examine long-term survival and quality of life of patients with early septic shock. DESIGN Prospective, randomized, parallel-group trial. SETTING Fifty-one hospitals in Australia, New Zealand, Finland, Hong Kong, and the Republic of Ireland. PATIENTS One-thousand five-hundred ninety-one patients who presented to the emergency department with early septic shock between October 2008 and April 2014, and were enrolled in the Australasian Resuscitation in Sepsis Evaluation trial. INTERVENTIONS Early goal-directed therapy versus usual care. MEASUREMENTS AND MAIN RESULTS Long-term survival was measured up to 12 months postrandomization. Health-related quality of life was measured using the EuroQoL-5D-3L, Short Form 36 and Assessment of Quality of Life 4D at baseline, and at 6 and 12 months following randomization. Mortality data were available for 1,548 patients (97.3%) and 1,515 patients (95.2%) at 6 and 12 months, respectively. Health-related quality of life data were available for 85.1% of survivors at 12 months. There were no significant differences in mortality between groups at either 6 months (early goal-directed therapy 21.8% vs usual care 22.6%; p = 0.70) or 12 months (early goal-directed therapy 26.4% vs usual care 27.9%; p = 0.50). There were no group differences in health-related quality of life at either 6 or 12 months (EuroQoL-5D-3L utility scores at 12 mo early goal-directed therapy 0.65 ± 0.33 vs usual care 0.64 ± 0.34; p = 0.50), with the health-related quality of life of both groups being significantly lower than population norms. CONCLUSIONS In patients presenting to the emergency department with early septic shock, early goal-directed therapy compared with usual care did not reduce mortality nor improve health-related quality of life at either 6 or 12 months.
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Rahmel T, Schmitz S, Nowak H, Schepanek K, Bergmann L, Halberstadt P, Hörter S, Peters J, Adamzik M. Long-term mortality and outcome in hospital survivors of septic shock, sepsis, and severe infections: The importance of aftercare. PLoS One 2020; 15:e0228952. [PMID: 32050005 PMCID: PMC7015408 DOI: 10.1371/journal.pone.0228952] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/26/2020] [Indexed: 12/29/2022] Open
Abstract
Patients with severe infections and especially sepsis have a high in-hospital mortality, but even hospital survivors face long-term sequelae, decreased health-related quality of life, and high risk of death, suggesting a great need for specialized aftercare. However, data regarding a potential benefit of post-discharge rehabilitation in these patients are scarce. In this retrospective matched cohort study the claim data of a large German statutory health care insurer was analyzed. 83,974 hospital survivors having suffered from septic shock, sepsis, and severe infections within the years 2009–2016 were identified using an ICD abstraction strategy closely matched to the current Sepsis-3 definition. Cases were analyzed and compared with their matched pairs to determine their 5-year mortality and the impact of post-discharge rehabilitation. Five years after hospital discharge, mortality of initial hospital survivors were still increased after septic shock (HRadj 2.03, 95%-CI 1.87 to 2.19; P<0.001), sepsis (HRadj 1.73, 95%-CI 1.71 to 1.76; P<0.001), and also in survivors of severe infections without organ dysfunction (HRadj 1.70, 95%-CI 1.65 to 1.74; P<0.001) compared to matched controls without infectious diseases. Strikingly, patients treated in rehabilitation facilities showed a significantly improved 5-year survival after suffering from sepsis or septic shock (HRadj 0.81, 95%-CI 0.77 to 0.85; P<0.001) as well as severe infections without organ dysfunction (HRadj 0.81, 95%-CI 0.73 to 0.90; P<0.001) compared to matched patients discharged to home or self-care. Long-term mortality and morbidity of hospital survivors are markedly increased after septic shock, sepsis and severe infections without organ dysfunction, but best 5-year survival was recorded in patients discharged to a rehabilitation facility in all three groups. Thus, our data suggest that specialized aftercare programs may help to improve long-term outcome in these patients and warrants more vigilance in future investigations.
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Affiliation(s)
- Tim Rahmel
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
- * E-mail:
| | - Stefanie Schmitz
- Institut für Versorgungsforschung der Knappschaft, Knappschaft, Bochum, Germany
| | - Hartmuth Nowak
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Kaspar Schepanek
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Lars Bergmann
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Peter Halberstadt
- Institut für Versorgungsforschung der Knappschaft, Knappschaft, Bochum, Germany
| | - Stefan Hörter
- Institut für Versorgungsforschung der Knappschaft, Knappschaft, Bochum, Germany
| | - Jürgen Peters
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum Essen, Essen, Germany
| | - Michael Adamzik
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
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Mohamed ZU, Prasannan P, Moni M, Edathadathil F, Prasanna P, Menon A, Nair S, Greeshma CR, Sathyapalan DT, Menon V, Menon V. Vitamin C Therapy for Routine Care in Septic Shock (ViCTOR) Trial: Effect of Intravenous Vitamin C, Thiamine, and Hydrocortisone Administration on Inpatient Mortality among Patients with Septic Shock. Indian J Crit Care Med 2020; 24:653-661. [PMID: 33024370 PMCID: PMC7519616 DOI: 10.5005/jp-journals-10071-23517] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Sepsis remains a leading cause of death worldwide despite advances in management strategies. Preclinical and observational studies have found mortality benefit with high-dose vitamin C in sepsis. Our study aims to prospectively evaluate the effect of intravenous hydrocortisone, vitamin C [ascorbic acid (AA)], and thiamine (HAT) administration in reducing inpatient all-cause mortality among patients with septic shock. Materials and methods Our single-center, prospective, open-label, randomized controlled trial recruited patients with admitting diagnosis of septic shock and assigned eligible patients (1:1) into either intervention (HAT) or control group (routine). The HAT group received intravenous combination of vitamin C (1.5 g every 6 hours), thiamine (200 mg every 12 hours), and hydrocortisone (50 mg every 6 hours) within 6 hours of onset of septic shock admission. The treatment was continued for at least 4 days, in addition to the routine standard of care provided to the control group. Thiamine and hydrocortisone use in control arm was not restricted. Vitamin C levels were estimated at baseline and at the end of the 4 days of treatment for both groups. The primary outcome evaluated was mortality during inpatient stay. Results Among 90 patients enrolled, 88 patients completed the study protocol. The baseline characteristics between the HAT (n = 45) and the routine (n = 43) groups were comparable. The all-cause mortality in the HAT cohort was 57% (26/45) compared to 53% (23/43) in the routine care group (p = 0.4, OR 1.19, 95% CI 0.51-2.76). The time to reversal of septic shock was significantly lower in the HAT (34.58 ± 22.63 hours) in comparison to the routine care (45.42 ± 24.4 hours) (p = 0.03, mean difference -10.84, 95% CI -20.8 to -0.87). No significant difference was observed between the HAT and the routine care with respect to changes in sequential organ failure assessment (SOFA) scores at 72 hours (2.23 ± 2.4 vs 1.38 ± 3.1), the use of mechanical ventilation (48% vs 46%), and mean Vasoactive Inotropic Score (7.77 ± 12.12 vs 8.86 ± 12.5). Conclusion Intravenous administration of vitamin C, thiamine, and hydrocortisone did not significantly improve the inpatient all-cause mortality among patients with septic shock. Clinical significance HAT protocol does not reduce hospital mortality but decreases time to shock reversal in septic shock. How to cite this article Mohamed ZU, Prasannan P, Moni M, Edathadathil F, Prasanna P, Menon A, et al. Vitamin C Therapy for Routine Care in Septic Shock (ViCTOR) Trial: Effect of Intravenous Vitamin C, Thiamine, and Hydrocortisone Administration on Inpatient Mortality among Patients with Septic Shock. Indian J Crit Care Med 2020;24(8):653-661.
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Affiliation(s)
- Zubair U Mohamed
- Department of Anesthesia and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Pratibha Prasannan
- Department of General Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Merlin Moni
- Department of General Medicine and Division of Infectious Diseases, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Fabia Edathadathil
- Department of Allied Health Sciences, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Preetha Prasanna
- Department of General Medicine and Division of Infectious Diseases, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Anup Menon
- Department of General Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Sabarish Nair
- Department of Emergency Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - C R Greeshma
- Department of Biostatistics, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Dipu T Sathyapalan
- Department of General Medicine and Division of Infectious Diseases, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Veena Menon
- Clinical Virology Laboratory, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Vidya Menon
- Department of General Medicine, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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Luethi N, Bailey M, Higgins A, Howe B, Peake S, Delaney A, Bellomo R. Gender differences in mortality and quality of life after septic shock: A post-hoc analysis of the ARISE study. J Crit Care 2019; 55:177-183. [PMID: 31739087 DOI: 10.1016/j.jcrc.2019.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/28/2019] [Accepted: 11/04/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE To assess the impact of gender and pre-menopausal state on short- and long-term outcomes in patients with septic shock. MATERIAL AND METHODS Cohort study of the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial, an international randomized controlled trial comparing early goal-directed therapy (EGDT) to usual care in patients with early septic shock, conducted between October 2008 and April 2014. The primary exposure in this analysis was legal gender and the secondary exposure was pre-menopausal state defined by chronological age (≤ 50 years). RESULTS 641 (40.3%) of all 1591 ARISE trial participants in the intention-to-treat population were females and overall, 337 (21.2%) (146 females) patients were 50 years of age or younger. After risk-adjustment, we could not identify any survival benefit for female patients at day 90 in the younger (≤50 years) (adjusted Odds Ratio (aOR): 0.91 (0.46-1.89), p = .85) nor in the older (>50 years) age-group (aOR: 1.10 (0.81-1.49), p = .56). Similarly, there was no gender-difference in ICU, hospital, 1-year mortality nor quality of life measures. CONCLUSIONS This post-hoc analysis of a large multi-center trial in early septic shock has shown no short- or long-term survival effect for women overall as well as in the pre-menopausal age-group.
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Affiliation(s)
- Nora Luethi
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alisa Higgins
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Belinda Howe
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sandra Peake
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Anthony Delaney
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Heidelberg, Australia
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Lam SW, Barreto EF, Scott R, Kashani KB, Khanna AK, Bauer SR. Cost-effectiveness of second-line vasopressors for the treatment of septic shock. J Crit Care 2019; 55:48-55. [PMID: 31706118 DOI: 10.1016/j.jcrc.2019.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/04/2019] [Accepted: 10/17/2019] [Indexed: 01/27/2023]
Abstract
PURPOSE To determine the cost-effectiveness of escalating doses of norepinephrine or norepinephrine plus the adjunctive use of vasopressin or angiotensin II as a second-line vasopressor for septic shock. MATERIALS AND METHODS Decision tree analysis was performed to compare costs and outcomes associated with norepinephrine monotherapy or the two adjunctive second-line vasopressors. Short- and long-term outcomes modeled included ICU survival and lifetime quality-adjusted-life-years (QALY) gained. Costs were modeled from a payer's perspective, with a willingness-to-pay threshold set at $100,000/unit gained. One-way (tornado diagrams) and probabilistic sensitivity analyses were performed. RESULTS Adjunctive vasopressin was the most cost-effective therapy, and dominated both norepinephrine monotherapy and adjunctive angiotensin II by producing higher ICU survival at less cost. For the lifetime horizon, while norepinephrine monotherapy was least expensive, adjunctive vasopressin was the most cost-effective with an incremental cost-effectiveness ratio of $19,762 / QALY gained. Although adjunctive angiotensin II produced more QALYs compared to norepinephrine monotherapy, it was dominated in the long-term evaluation by second-line vasopressin. Sensitivity analyses demonstrated model robustness and medication costs were not significant drivers of model results. CONCLUSIONS Vasopressin is the most cost-effective second-line vasopressor in both the short- and long-term evaluations. Vasopressor price is a minor contributor to overall cost.
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Affiliation(s)
- Simon W Lam
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA.
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Rachael Scott
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA; Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA; Wake Forest Center for Biomedical Informatics, and the Critical Injury, Illness and Recovery Research Center (CIIRRC), USA
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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Sarin J, Salonen J, Hirvonen J, Jero J. From urinary tract infection to cochlear implantation: A case report. ACTA OTO-LARYNGOLOGICA CASE REPORTS 2019. [DOI: 10.1080/23772484.2019.1673662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Jussi Sarin
- Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Hospital and University of Turku, Turku, Finland
| | - Jaakko Salonen
- Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Hospital and University of Turku, Turku, Finland
| | - Jussi Hirvonen
- Department of Radiology, University of Turku, Turku, Finland
| | - Jussi Jero
- Department of Otorhinolaryngology-Head and Neck Surgery, Turku University Hospital and University of Turku, Turku, Finland
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Sadaka F, Grady J, Organti N, Donepudi B, Korobey M, Tannehill D, O'Brien J. Ascorbic Acid, Thiamine, and Steroids in Septic Shock: Propensity Matched Analysis. J Intensive Care Med 2019; 35:1302-1306. [PMID: 31315499 DOI: 10.1177/0885066619864541] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION We aimed to study the use of ascorbic acid, thiamine, and steroids (ATS) in patients with septic shock (SS). METHODS Data on 62 patients with SS were collected from Acute Physiologic and Chronic Health Evaluation (APACHE) Outcome database and medical records. The ATS group received full doses of intravenous (IV) ATS (ascorbic acid [1.5 g every 6 hours for 4 days], hydrocortisone [50 mg every 6 hours for 7 days], and thiamine [200 mg every 12 hours for 4 days]). Data included age, gender, APACHE III, acute physiologic score (APS), mechanical ventilation (MV), lactic acid (LA), serum creatinine (Cr), duration of vasopressors (VP, days, median: interquartile ranges [IQR]: [Q1, Q3]), MV-free days (median: IQR [Q1-Q3]), percentage of patients requiring renal replacement therapy (RRT) for acute kidney injury (AKI), and mortality. Propensity analysis was used to match patients on age, gender, MV, APACHE III, APS, LA, and Cr. RESULTS The ATS group had longer duration of VP (4.5: 4.0-6.0 vs 2.0: 1.0-2.0, P = .001), similar RRT for AKI (26% vs 29%, P = .8), similar MV-free days (10.2: 5.0-15.0 vs 10.2: 1.6-18.0, P > .9), lower intensive care unit mortality (9.6% vs 42%, P = .004), and a trend toward lower hospital mortality (29% vs 45%, P = .2) compared to the NO ATS group. CONCLUSIONS The use of IV ascorbic acid, thiamine, and hydrocortisone might be beneficial in patients with SS.
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Affiliation(s)
- Farid Sadaka
- 24116Mercy Hospital St Louis/St. Louis University, St. Louis, MO, USA
| | - Justin Grady
- 24116Mercy Hospital St Louis/St. Louis University, St. Louis, MO, USA
| | - Nikhil Organti
- 24116Mercy Hospital St Louis/St. Louis University, St. Louis, MO, USA
| | - Bhargavi Donepudi
- 24116Mercy Hospital St Louis/St. Louis University, St. Louis, MO, USA
| | - Matthew Korobey
- 24116Mercy Hospital St Louis/St. Louis University, St. Louis, MO, USA
| | - David Tannehill
- 24116Mercy Hospital St Louis/St. Louis University, St. Louis, MO, USA
| | - Jacklyn O'Brien
- 24116Mercy Hospital St Louis/St. Louis University, St. Louis, MO, USA
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Labroca P, Chiesa G, Laroyenne I, Borrini L, Klotz R, Phan Sy Q, Cristina MC, Martinez AB, Bollaert PE, Paysant J, Lemarié J. Quality of life assessment following amputation for septic shock: a long-term descriptive survey after symmetric peripheral gangrene. J Crit Care 2019; 53:231-235. [PMID: 31277050 DOI: 10.1016/j.jcrc.2019.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/27/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To assess health-related quality of life (HRQOL) following rehabilitation of amputees suffering symmetric peripheral gangrene (SPG) after septic shock. MATERIAL AND METHODS A retrospective cohort study was conducted in nine French specialized rehabilitation centers. Thirty-two ICU adult patients hospitalized between 2005 and 2015 for septic shock who additionally presented with SPG resulting in at least two major amputations were enrolled. HRQOL was assessed by EQ-5D-3 L questionnaire. RESULTS All patients (mean ICU length of stay 39 ± 22d, SAPS II 58 ± 18) had both lower limbs amputated and 84% were quadruple amputees. HRQOL, assessed 4.8 ± 2.8 years after amputation, was inferior to the French reference. However, patients' self-rated health status was similar to the reference at the time of HRQOL assessment. The main factor of impaired HRQOL was intense phantom pain, not the mobility or self-care dimensions of EQ-5D. All patients except one preferred to be treated again for SPG despite disability. CONCLUSION ICU survivors referred to rehabilitation centers after SPG-related amputations had impaired HRQOL. At the time of HRQOL assessment, they considered themselves in good health and preferred to be treated again despite disability. Appraisal of long-term functional outcome should not be used to guide end-of-life decision-making in this situation.
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Affiliation(s)
- Pierre Labroca
- Réanimation médicale, hôpital central, C.H.R.U. de Nancy, Nancy, France
| | - Gérard Chiesa
- Service de rééducation et d'appareillage, Institut Robert Merle d'Aubigné, Valenton, France
| | - Isabelle Laroyenne
- Service de médecine physique et de réadaptation, Centre Médico-Chirurgical de Réadaptation des Massues, Lyon, France
| | - Léo Borrini
- Service de médecine physique et de réadaptation, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Rémi Klotz
- Service de médecine physique et de réadaptation, centre de médecine physique et de réadaptation de la tour de Gassies, Bruges, France
| | - Quoc Phan Sy
- Service de médecine physique et de réadaptation, Hôpital la renaissance sanitaire, Villiers-Saint-Denis, France
| | | | - Anne Brunon Martinez
- Service de rééducation réadaptation, Hôpital Universitaire du Grau du Roi, Le Grau du Roi, France
| | | | - Jean Paysant
- Centre Louis Pierquin, Institut Régional de Médecine Physique et de Réadaptation, Nancy, France
| | - Jérémie Lemarié
- Réanimation médicale, hôpital central, C.H.R.U. de Nancy, Nancy, France.
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32
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Masood H, Burki AM, Sultan A, Sharif H, Ghauri A, Khan S, Qureshi MSS, Qadeer A, Rasheed G. Effect of Intravenous Vitamin C, Thiamine, and Hydrocortisone (The Metabolic Resuscitation Protocol) on Early Weaning from Vasopressors in Patients with Septic Shock. A Descriptive Case Series Study. Cureus 2019; 11:e5016. [PMID: 31497446 PMCID: PMC6716767 DOI: 10.7759/cureus.5016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES The aim of this study was to assess the efficacy of intravenous vitamin C, hydrocortisone, and thiamine in early weaning (within 48 hours) from vasopressor support in patients with septic shock. We also aimed to assess mortality and intensive care unit (ICU) stay. STUDY DESIGN We conducted a descriptive case series study of 50 patients with septic shock who were admitted in the ICU of the Combined Military Hospital Rawalpindi in Pakistan from August 2017 until April 2018. MATERIALS AND METHODS The study included men and women (16 to 80 years of age) who were admitted to the ICU with septic shock. Data were analysed using the IBM Statistical Package for Social Sciences (SPSS), version 18.0 (IBM Corp., Armonk, NY, USA). Inferential analysis was done with the help of simple and multivariate binary logistic regression that generated unadjusted and adjusted odds ratios (OR), respectively. RESULTS Of the 50 patients, 56% (N = 28) were male with a mean age of the respondents being 46.7 ± 18.4. Eighty-four percent were successfully weaned off vasopressors within 48 hours. Median days in the ICU were reported as 8.3 (interquartile range (IQR) = 5). Primary bacteremia (34%) was the most reported cause of ICU admission. The most common vasopressor was norepinephrine and its mean dose was 21.6 ± 10.7 microgram/min. The ICU mortality was observed at 52% (N = 26). Unadjusted OR showed a dose of norepinephrine, Sequential Organ Failure Assessment (SOFA) score, plasma procalcitonin, and plasma lactate to be significant predictors (p-value < 0.05), while the adjusted odds ratio (AOR) showed only a dose of norepinephrine to be a statistically significant predictor (AOR = 0.804, 95% CI = 0.674 - 0.960; p-value = 0.016). CONCLUSION The administration of intravenous vitamin C, hydrocortisone, and thiamine to patients with septic shock was successful in early weaning from vasopressors. There was also a reduction in procalcitonin and lactate levels, as well as the SOFA score. Further trials are needed to determine whether the metabolic resuscitation protocol can become part of the treatment for septic shock.
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Affiliation(s)
- Hassan Masood
- Internal Medicine, Shifa International Hospital, Islamabad, PAK
| | - Ahmed M Burki
- Anesthesiology and Critical Care, Combined Military Hospital, Rawalpindi, PAK
| | - Anum Sultan
- Anesthesiology, Combined Military Hospital, Rawalpindi, PAK
| | - Hina Sharif
- Public Health, Al-Shifa School of Public Health, Islamabad, PAK
| | - Asim Ghauri
- Anesthesiology and Critical Care, Combined Military Hospital, Rawalpindi, PAK
| | - Sehrish Khan
- Ophthalmology, Al-Shifa Trust Eye Hospital, Rawalpindi, PAK
| | | | - Aayesha Qadeer
- Internal Medicine, Shifa International Hospital, Islamabad, PAK
| | - Ghulam Rasheed
- Internal Medicine, Shifa International Hospital, Islamabad, PAK
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33
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Nedeva C, Menassa J, Puthalakath H. Sepsis: Inflammation Is a Necessary Evil. Front Cell Dev Biol 2019; 7:108. [PMID: 31281814 PMCID: PMC6596337 DOI: 10.3389/fcell.2019.00108] [Citation(s) in RCA: 181] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/29/2019] [Indexed: 12/12/2022] Open
Abstract
Sepsis is one of the leading causes of deaths world-wide and yet there are no therapies available other than ICU treatment. The patient outcome is determined by a complex interplay between the pro and anti-inflammatory responses of the body i.e., a homeostatic balance between these two competing events to be achieved for the patient’s recovery. The initial attempts on drug development mainly focused on controlling inflammation, however, without any tangible outcome. This was despite most deaths occurring during the immune paralysis stage of this biphasic disease. Recently, the focus has been shifting to understand immune paralysis (caused by apoptosis and by anti-inflammatory cytokines) to develop therapeutic drugs. In this review we put forth an argument for a proper understanding of the molecular basis of inflammation as well as apoptosis for developing an effective therapy.
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Affiliation(s)
- Christina Nedeva
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science, La Trobe University, Melbourne, VIC, Australia
| | - Joseph Menassa
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science, La Trobe University, Melbourne, VIC, Australia
| | - Hamsa Puthalakath
- Department of Biochemistry and Genetics, La Trobe Institute for Molecular Science, La Trobe University, Melbourne, VIC, Australia
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34
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Brandstetter S, Dodoo-Schittko F, Brandl M, Blecha S, Bein T, Apfelbacher C. Ambulatory and stationary healthcare use in survivors of ARDS during the first year after discharge from ICU: findings from the DACAPO cohort. Ann Intensive Care 2019; 9:70. [PMID: 31201576 PMCID: PMC6570725 DOI: 10.1186/s13613-019-0544-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/04/2019] [Indexed: 12/25/2022] Open
Abstract
Background For many survivors of acute respiratory distress syndrome (ARDS), the process from discharge from intensive care unit (ICU) to recovery is long and difficult. However, healthcare use after discharge from ICU has received only little attention by research. This study sets out to investigate the extent of ambulatory and stationary healthcare use among survivors of ARDS in Germany (multicenter DACAPO cohort) and to analyze predictors of stationary healthcare use. Results A total of 396 survivors of ARDS provided data at 1 year after discharge from ICU. Fifty percent of 1-year survivors were hospitalized for 48 days or longer after discharge from ICU, with 10% spending more than six out of 12 months in stationary care. The duration of hospitalization increased significantly by the length of the initial ICU stay. All participants reported at least one outpatient visit (including visits to general practitioners), and 50% contacted four or more different medical specialties within the first year after discharge from ICU. Conclusions For most of the patients, the first year after ARDS is characterized by an extensive amount of healthcare utilization, especially with regard to stationary health care. These findings shed light on the substantial morbidity of patients after ARDS and contribute to a better understanding of the situation of patients following discharge from ICU.
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Affiliation(s)
- Susanne Brandstetter
- Medical Sociology, Institute for Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany.
| | - Frank Dodoo-Schittko
- Medical Sociology, Institute for Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - Magdalena Brandl
- Medical Sociology, Institute for Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany
| | - Sebastian Blecha
- Department of Anesthesia and Operative Intensive Care, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Thomas Bein
- Department of Anesthesia and Operative Intensive Care, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Christian Apfelbacher
- Medical Sociology, Institute for Epidemiology and Preventive Medicine, University of Regensburg, Dr.-Gessler-Str. 17, 93051, Regensburg, Germany.,Institute of Social Medicine and Health Economics (ISMHE), University of Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
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35
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Danahy DB, Kurup SP, Winborn CS, Jensen IJ, Harty JT, Griffith TS, Badovinac VP. Sepsis-Induced State of Immunoparalysis Is Defined by Diminished CD8 T Cell-Mediated Antitumor Immunity. THE JOURNAL OF IMMUNOLOGY 2019; 203:725-735. [PMID: 31189573 DOI: 10.4049/jimmunol.1900435] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/27/2019] [Indexed: 01/15/2023]
Abstract
Patients who survive sepsis experience long-term immunoparalysis characterized by numerical and/or functional lesions in innate and adaptive immunity that increase the host's susceptibility to secondary complications. The extent to which tumor development/growth is affected in sepsis survivors remains unknown. In this study, we show cecal ligation and puncture (CLP) surgery renders mice permissive to increased B16 melanoma growth weeks/months after sepsis induction. CD8 T cells provide partial protection in this model, and tumors from sepsis survivors had a reduced frequency of CD8 tumor-infiltrating lymphocytes (TILs) concomitant with an increased tumor burden. Interestingly, the postseptic environment reduced the number of CD8 TILs with high expression of activating/inhibitory receptors PD-1 and LAG-3 (denoted PD-1hi) that define a tumor-specific CD8 T cell subset that retain some functional capacity. Direct ex vivo analysis of CD8 TILs from CLP hosts showed decreased proliferation, IFN-γ production, and survival compared with sham counterparts. To increase the frequency and/or functional capacity of PD-1hi CD8 TILs in tumor-bearing sepsis survivors, checkpoint blockade therapy using anti-PD-L1/anti-LAG-3 mAb was administered before or after the development of sepsis-induced lesions in CD8 TILs. Checkpoint blockade did not reduce tumor growth in CLP hosts when therapy was administered after PD-1hi CD8 TILs had become reduced in frequency and/or function. However, early therapeutic intervention before lesions were observed significantly reduced tumor growth to levels seen in nonseptic hosts receiving therapy. Thus, sepsis-induced immunoparalysis is defined by diminished CD8 T cell-mediated antitumor immunity that can respond to timely checkpoint blockade, further emphasizing the importance of early cancer detection in hosts that survive sepsis.
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Affiliation(s)
- Derek B Danahy
- Department of Pathology, University of Iowa, Iowa City, IA 52242.,Interdisciplinary Program in Immunology, University of Iowa, Iowa City, IA 52242
| | - Samarchith P Kurup
- Department of Microbiology and Immunology, University of Iowa, Iowa City, IA 52242; and
| | | | - Isaac J Jensen
- Department of Pathology, University of Iowa, Iowa City, IA 52242.,Interdisciplinary Program in Immunology, University of Iowa, Iowa City, IA 52242
| | - John T Harty
- Department of Pathology, University of Iowa, Iowa City, IA 52242.,Interdisciplinary Program in Immunology, University of Iowa, Iowa City, IA 52242.,Department of Microbiology and Immunology, University of Iowa, Iowa City, IA 52242; and
| | - Thomas S Griffith
- Department of Urology, University of Minnesota, Minneapolis, MN 55414
| | - Vladimir P Badovinac
- Department of Pathology, University of Iowa, Iowa City, IA 52242; .,Interdisciplinary Program in Immunology, University of Iowa, Iowa City, IA 52242.,Department of Microbiology and Immunology, University of Iowa, Iowa City, IA 52242; and
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36
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Hager DN, Hooper MH, Bernard GR, Busse LW, Ely EW, Fowler AA, Gaieski DF, Hall A, Hinson JS, Jackson JC, Kelen GD, Levine M, Lindsell CJ, Malone RE, McGlothlin A, Rothman RE, Viele K, Wright DW, Sevransky JE, Martin GS. The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) Protocol: a prospective, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled, clinical trial. Trials 2019; 20:197. [PMID: 30953543 PMCID: PMC6451231 DOI: 10.1186/s13063-019-3254-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/27/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sepsis accounts for 30% to 50% of all in-hospital deaths in the United States. Other than antibiotics and source control, management strategies are largely supportive with fluid resuscitation and respiratory, renal, and circulatory support. Intravenous vitamin C in conjunction with thiamine and hydrocortisone has recently been suggested to improve outcomes in patients with sepsis in a single-center before-and-after study. However, before this therapeutic strategy is adopted, a rigorous assessment of its efficacy is needed. METHODS The Vitamin C, Thiamine and Steroids in Sepsis (VICTAS) trial is a prospective, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled trial. It will enroll patients with sepsis causing respiratory or circulatory compromise or both. Patients will be randomly assigned (1:1) to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 h or matching placebos until a total of 16 administrations have been completed or intensive care unit discharge occurs (whichever is first). Patients randomly assigned to the comparator group are permitted to receive open-label stress-dose steroids at the discretion of the treating clinical team. The primary outcome is consecutive days free of ventilator and vasopressor support (VVFDs) in the 30 days following randomization. The key secondary outcome is mortality at 30 days. Sample size will be determined adaptively by using interim analyses with pre-stated stopping rules to allow the early recognition of a large mortality benefit if one exists and to refocus on the more sensitive outcome of VVFDs if an early large mortality benefit is not observed. DISCUSSION VICTAS is a large, multi-center, double-blind, adaptive sample size, randomized, placebo-controlled trial that will test the efficacy of vitamin C, thiamine, and hydrocortisone as a combined therapy in patients with respiratory or circulatory dysfunction (or both) resulting from sepsis. Because the components of this therapy are inexpensive and readily available and have very favorable risk profiles, demonstrated efficacy would have immediate implications for the management of sepsis worldwide. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03509350 . First registered on April 26, 2018, and last verified on December 20, 2018. Protocol version: 1.4, January 9, 2019.
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Affiliation(s)
- David N. Hager
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Johns Hopkins University, 1800 Orleans Street, Suite 9121, Baltimore, MD 21287 USA
| | - Michael H. Hooper
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Eastern Virginia Medical School and Sentara Healthcare, Norfolk, VA USA
| | - Gordon R. Bernard
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Laurence W. Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA USA
| | - E. Wesley Ely
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN USA
- Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN USA
| | - Alpha A. Fowler
- Division of Pulmonary Disease & Critical Care Medicine, Department of Internal Medicine, The VCU Johnson Center for Critical Care and Pulmonary Research, Virginia Commonwealth University School of Medicine, Richmond, VA USA
| | - David F. Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Alex Hall
- Department of Emergency Medicine, Emory University, Atlanta, GA USA
- Grady Memorial Hospital, Atlanta, GA USA
| | - Jeremiah S. Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD USA
| | - James C. Jackson
- Division of Pulmonary & Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN USA
- Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN USA
- Department of Psychiatry, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Gabor D. Kelen
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD USA
| | - Mark Levine
- Molecular & Clinical Nutrition Section, Intramural Research Program, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Bethesda, MD USA
| | | | - Richard E. Malone
- Investigational Drug Service, Vanderbilt University Medical Center, Nashville, TN USA
| | | | - Richard E. Rothman
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD USA
| | | | - David W. Wright
- Department of Emergency Medicine, Emory University, Atlanta, GA USA
- Grady Memorial Hospital, Atlanta, GA USA
| | - Jonathan E. Sevransky
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA USA
| | - Greg S. Martin
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA USA
- Grady Memorial Hospital, Atlanta, GA USA
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37
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Health related quality of life and predictive factors six months after intensive care unit discharge. Anaesth Crit Care Pain Med 2019; 38:137-141. [DOI: 10.1016/j.accpm.2018.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 05/07/2018] [Accepted: 05/07/2018] [Indexed: 12/13/2022]
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38
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Marik PE. Hydrocortisone, Ascorbic Acid and Thiamine (HAT Therapy) for the Treatment of Sepsis. Focus on Ascorbic Acid. Nutrients 2018; 10:nu10111762. [PMID: 30441816 PMCID: PMC6265973 DOI: 10.3390/nu10111762] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 10/30/2018] [Accepted: 11/08/2018] [Indexed: 12/21/2022] Open
Abstract
Sepsis is a devastating disease that carries an enormous toll in terms of human suffering and lives lost. Over 100 novel pharmacologic agents that targeted specific molecules or pathways have failed to improve the outcome of sepsis. Preliminary data suggests that the combination of Hydrocortisone, Ascorbic Acid and Thiamine (HAT therapy) may reduce organ failure and mortality in patients with sepsis and septic shock. HAT therapy is based on the concept that a combination of readily available, safe and cheap agents, which target multiple components of the host’s response to an infectious agent, will synergistically restore the dysregulated immune response and thereby prevent organ failure and death. This paper reviews the rationale for HAT therapy with a focus on vitamin C.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
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39
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Tan TL, Tang YJ, Ching LJ, Abdullah N, Neoh HM. Comparison of Prognostic Accuracy of the quick Sepsis-Related Organ Failure Assessment between Short- & Long-term Mortality in Patients Presenting Outside of the Intensive Care Unit - A Systematic Review & Meta-analysis. Sci Rep 2018; 8:16698. [PMID: 30420768 PMCID: PMC6232181 DOI: 10.1038/s41598-018-35144-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 10/30/2018] [Indexed: 12/29/2022] Open
Abstract
The purpose of this meta-analysis was to compare the ability of the qSOFA in predicting short- (≤30 days or in-hospital mortality) and long-term (>30 days) mortality among patients outside the intensive care unit setting. Studies reporting on the qSOFA and mortality were searched using MEDLINE and SCOPUS. Studies were included if they involved patients presenting to the ED with suspected infection and usage of qSOFA score for mortality prognostication. Data on qSOFA scores and mortality rates were extracted from 36 studies. The overall pooled sensitivity and specificity for the qSOFA were 48% and 86% for short-term mortality and 32% and 92% for long-term mortality, respectively. Studies reporting on short-term mortality were heterogeneous (Odd ratio, OR = 5.6; 95% CI = 4.6-6.8; Higgins's I2 = 94%), while long-term mortality studies were homogenous (OR = 4.7; 95% CI = 3.5-6.1; Higgins's I2 = 0%). There was no publication bias for short-term mortality analysis. The qSOFA score showed poor sensitivity but moderate specificity for both short and long-term mortality, with similar performance in predicting both short- and long- term mortality. Geographical region was shown to have nominal significant (p = 0.05) influence on qSOFA short-term mortality prediction.
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Affiliation(s)
- Toh Leong Tan
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia.
| | - Ying Jing Tang
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Ling Jing Ching
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Noraidatulakma Abdullah
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
| | - Hui-Min Neoh
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Kuala Lumpur, Malaysia
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40
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Montgomery CL, Rolfson DB, Bagshaw SM. Frailty and the Association Between Long-Term Recovery After Intensive Care Unit Admission. Crit Care Clin 2018; 34:527-547. [PMID: 30223992 DOI: 10.1016/j.ccc.2018.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Frailty is common, although infrequently screened for among patients admitted to intensive care. Frailty has been the focus of research in geriatric medicine; however, its epidemiology and interaction with critical illness have only recently been studied. Instruments to screen for and measure frailty require refinement in intensive care settings. Frail critically ill patients are at higher risk of poor outcomes. Frail survivors of critical illness are high users of health resources. Further research is needed to understand how frailty assessment can inform decision-making before and during an episode of critical illness and during an intensive care course for frail patients.
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Affiliation(s)
- Carmel L Montgomery
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, 11350 83 Avenue, Edmonton, Alberta T6G 2G3, Canada
| | - Darryl B Rolfson
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, 1-198 Clinical Sciences Building, 11350 83 Avenue, Edmonton, Alberta T6G 2G3, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, 11350 83 Avenue, Edmonton, Alberta T6G 2G3, Canada.
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Hodgson CL, Walsh TS, Lone N. The long road home: are outcomes different for patients with sepsis? Intensive Care Med 2018; 44:1556-1557. [PMID: 30022235 DOI: 10.1007/s00134-018-5301-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Affiliation(s)
- C L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.
| | - T S Walsh
- University of Edinburgh, Edinburgh, UK
| | - N Lone
- University of Edinburgh, Edinburgh, UK
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The Cost-Effectiveness of Rapid Diagnostic Testing for the Diagnosis of Bloodstream Infections with or without Antimicrobial Stewardship. Clin Microbiol Rev 2018; 31:31/3/e00095-17. [PMID: 29848775 DOI: 10.1128/cmr.00095-17] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Bloodstream infections are associated with considerable morbidity and health care costs. Molecular rapid diagnostic tests (mRDTs) are a promising complement to conventional laboratory methods for the diagnosis of bloodstream infections and may reduce the time to effective therapy among patients with bloodstream infections. The concurrent implementation of antimicrobial stewardship programs (ASPs) may reinforce these benefits. The aim of this study was to evaluate the cost-effectivenesses of competing strategies for the diagnosis of bloodstream infection alone or combined with an ASP. To this effect, we constructed a decision-analytic model comparing 12 strategies for the diagnosis of bloodstream infection. The main arms compared the use of mRDT and conventional laboratory methods with or without an ASP. The baseline strategy used as the standard was the use of conventional laboratory methods without an ASP, and our decision-analytic model assessed the cost-effectivenesses of 5 principal strategies: mRDT (with and without an ASP), mRDT with an ASP, mRDT without an ASP, conventional laboratory methods with an ASP, and conventional laboratory methods without an ASP. Furthermore, based on the availability of data in the literature, we assessed the cost-effectivenesses of 7 mRDT subcategories, as follows: PCR with an ASP, matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) analysis with an ASP, peptide nucleic acid fluorescent in situ hybridization (PNA-FISH) with an ASP, a blood culture nanotechnology microarray system for Gram-negative bacteria (BC-GP) with an ASP, a blood culture nanotechnology microarray system for Gram-positive bacteria (BC-GN) with an ASP, PCR without an ASP, and PNA-FISH without an ASP. Our patient population consisted of adult inpatients in U.S. hospitals with suspected bloodstream infection. The time horizon of the model was the projected life expectancy of the patients. In a base-case analysis, cost-effectiveness was determined by calculating the numbers of bloodstream infection deaths averted, the numbers of quality-adjusted life years gained, and incremental cost-effectiveness ratios (ICERs). In a probabilistic analysis, uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. In the base-case analysis, MALDI-TOF analysis with an ASP was the most cost-effective strategy, resulting in savings of $29,205 per quality-adjusted life year and preventing 1 death per 14 patients with suspected bloodstream infection tested compared to conventional laboratory methods without an ASP (ICER, -$29,205/quality-adjusted life year). BC-GN with an ASP (ICER, -$23,587/quality-adjusted life year), PCR with an ASP (ICER, -$19,833/quality-adjusted life year), and PCR without an ASP (ICER, -$21,039/quality-adjusted life year) were other cost-effective options. In the probabilistic analysis, mRDT was dominant and cost-effective in 85.1% of simulations. Importantly, mRDT with an ASP had an 80.0% chance of being cost-effective, while mRDT without an ASP had only a 41.1% chance. In conclusion, our findings suggest that mRDTs are cost-effective for the diagnosis of patients with suspected bloodstream infection and can reduce health care expenditures. Notably, the combination of mRDT and an ASP can result in substantial health care savings.
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McNamara JF, Righi E, Wright H, Hartel GF, Harris PNA, Paterson DL. Long-term morbidity and mortality following bloodstream infection: A systematic literature review. J Infect 2018; 77:1-8. [PMID: 29746948 DOI: 10.1016/j.jinf.2018.03.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 03/17/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Bloodstream infection results in significant short-term morbidity and mortality. No literature review has studied the long-term outcome following a bloodstream infection. This PROSPERO registered systematic review evaluated studies, which measured the association of a bloodstream infection with long-term morbidity and mortality. METHODS Databases were systematically searched for studies of adult patients reporting morbidity and/or mortality one year or more following a bloodstream infection in comparison to a matched cohort without a bloodstream infection. RESULTS Ten observational studies were included in the final analysis. Five studies assessed only mortality, two assessed morbidity and mortality and three studies assessed morbidity only. The one year mortality ranged from between 8 and 48% for patients with bloodstream infection. The pooled risk ratio of death at one year was significantly higher for patients with bloodstream infection when compared to the matched cohort (RR 4.04 [95% CI 1.84-8.87]). CONCLUSIONS Bloodstream infection was associated with poor long-term outcome measured at one year when compared to matched controls. More evidence is needed to determine if this association is causative.
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Affiliation(s)
- John F McNamara
- Centre for Clinical Research, Royal Brisbane and Women's Hospital, University of Queensland, Building 71/918, Brisbane QLD 4029, Australia; The Prince Charles Hospital, Chermside, Brisbane, Australia.
| | - Elda Righi
- Centre for Clinical Research, Royal Brisbane and Women's Hospital, University of Queensland, Building 71/918, Brisbane QLD 4029, Australia; Infectious Diseases Division, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Hugh Wright
- Centre for Clinical Research, Royal Brisbane and Women's Hospital, University of Queensland, Building 71/918, Brisbane QLD 4029, Australia
| | - Gunter F Hartel
- Statistics Group, Berghofer Centre, Queensland Institute of Medical Research, Brisbane, Australia
| | - Patrick N A Harris
- Centre for Clinical Research, Royal Brisbane and Women's Hospital, University of Queensland, Building 71/918, Brisbane QLD 4029, Australia
| | - David L Paterson
- Centre for Clinical Research, Royal Brisbane and Women's Hospital, University of Queensland, Building 71/918, Brisbane QLD 4029, Australia
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Vardakas KZ, Voulgaris GL, Maliaros A, Samonis G, Falagas ME. Prolonged versus short-term intravenous infusion of antipseudomonal β-lactams for patients with sepsis: a systematic review and meta-analysis of randomised trials. THE LANCET. INFECTIOUS DISEASES 2018; 18:108-120. [DOI: 10.1016/s1473-3099(17)30615-1] [Citation(s) in RCA: 163] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/07/2017] [Accepted: 09/25/2017] [Indexed: 12/13/2022]
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Sepsis Survivors Admitted to Skilled Nursing Facilities: Cognitive Impairment, Activities of Daily Living Dependence, and Survival. Crit Care Med 2017; 46:37-44. [PMID: 28991827 DOI: 10.1097/ccm.0000000000002755] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Severe sepsis survivors frequently experience cognitive and physical functional impairment. The degree of impairment and its association with mortality is understudied, particularly among those discharged to a skilled nursing facility. Our objective was to quantify the cognitive and physical impairment among severe sepsis survivors discharged to a skilled nursing facility and to investigate the relationship between impairment and long-term mortality. DESIGN Retrospective cohort study. SETTING United States. SUBJECTS Random 5% sample of Medicare patients discharged following severe sepsis hospitalization, 2005-2009 (n = 135,370). MEASUREMENT AND MAIN RESULTS Medicare data were linked with the Minimum Data Set; Minimum Data Set-Cognition Scale was used to assess cognitive function, and the Minimum Data Set activities of daily living hierarchical scale was used to assess functional dependence. Associations were evaluated using multivariable logistic regression, Kaplan-Meier curves, and Cox proportional hazards regression. Of 66,540 beneficiaries admitted to a skilled nursing facility following severe sepsis, 34% had severe or very severe cognitive impairment, and 72.5% had maximal, dependence, or total dependence in activities of daily living. Median survival was 19.4 months for those discharged to a skilled nursing facility without having been in a skilled nursing facility in the preceding 1 year and 10.4 months for those discharged to a skilled nursing facility who had spent time in a skilled nursing facility in the prior year. The adjusted hazard ratio for death was 3.1 for those with very severe cognitive impairment relative to those who were cognitively intact (95% CI, 2.9-3.2; p < 0.001) and 4.3 for those with "total dependence" in activities of daily livings relative to those who were independent (95% CI, 3.8-5.0; p < 0.001). CONCLUSIONS Discharge to a skilled nursing facility following severe sepsis hospitalization among Medicare beneficiaries was associated with shorter survival, and cognitive impairment and activities of daily living dependence were each strongly associated with shortened survival. These findings can inform decision-making by patients and physicians and underscores high palliative care needs among sepsis survivors discharged to skilled nursing facility.
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Wendelbo Ø, Hervig T, Haugen O, Seghatchian J, Reikvam H. Microcirculation and red cell transfusion in patients with sepsis. Transfus Apher Sci 2017; 56:900-905. [PMID: 29158076 DOI: 10.1016/j.transci.2017.11.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Early identification of sepsis followed by diagnostic blood cultures and prompt administration of appropriate intravenous antibiotics covering all likely pathogen remains the corner stone in the initial management of sepsis. Source control, obtained by harvesting microbiological cultures and removal or drainage of the infected foci, is mandatory. However, optimization of hemodynamically unstable patients including volume support supplemented with vasopressor, inotropic and transfusion of red blood cells (RBCs) in case of persistent hypoperfusion have the potential to reduce morbidity and mortality. Given the imbalance between the ability of the cardiovascular system to deliver enough oxygen to meet the oxygen demand, transfusion of RBCs should theoretically provide the ideal solution to the challenge. However, both changes in the septic patients' RBCs induced by endogenous factors as well as the storage lesion affecting transfused RBCs have negative effects on the microcirculation. RBC morphology, distribution of fatty acids on the membrane surface, RBC deformability needed for capillary circulation and the nitrogen oxide (NO) signaling systems are involved. Although these deteriorating effects develop during storage, transfusion of fresh RBCs has not proven to be beneficial, possibly due to limitations of the studies performed. Until better evidence exists, transfusion guidelines recommend a restrictive strategy of RBC transfusion i.e. transfuse when hemoglobin (Hb)<7g/dL in septic patients.
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Affiliation(s)
| | - Tor Hervig
- Department of Clinical Science, University of Bergen, Bergen, Norway; Department of immunology and Transfusion Medicine, Haukeland University Hospital, Norway
| | - Oddbjørn Haugen
- Department of Clinical Medicine, University of Bergen, Norway; Department of Anesthesiology, Haukeland University Hospital, Norway
| | - Jerard Seghatchian
- International Consultancy in Blood Components Quality/Safety Improvement and DDR Strategies, London, United Kingdom.
| | - Håkon Reikvam
- Department of Medicine, Haukeland University Hospital, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
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Lindemark F, Haaland ØA, Kvåle R, Flaatten H, Norheim OF, Johansson KA. Costs and expected gain in lifetime health from intensive care versus general ward care of 30,712 individual patients: a distribution-weighted cost-effectiveness analysis. Crit Care 2017; 21:220. [PMID: 28830479 PMCID: PMC5567919 DOI: 10.1186/s13054-017-1792-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 07/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinicians, hospital managers, policy makers, and researchers are concerned about high costs, increased demand, and variation in priorities in the intensive care unit (ICU). The objectives of this modelling study are to describe the extra costs and expected health gains associated with admission to the ICU versus the general ward for 30,712 patients and the variation in cost-effectiveness estimates among subgroups and individuals, and to perform a distribution-weighted economic evaluation incorporating extra weighting to patients with high severity of disease. METHODS We used a decision-analytic model that estimates the incremental cost per quality-adjusted life year (QALY) gained (ICER) from ICU admission compared with general ward care using Norwegian registry data from 2008 to 2010. We assigned increasing weights to health gains for those with higher severity of disease, defined as less expected lifetime health if not admitted. The study has inherent uncertainty of findings because a randomized clinical trial comparing patients admitted or rejected to the ICU has never been performed. Uncertainty is explored in probabilistic sensitivity analysis. RESULTS The mean cost-effectiveness of ICU admission versus ward care was €11,600/QALY, with 1.6 QALYs gained and an incremental cost of €18,700 per patient. The probability (p) of cost-effectiveness was 95% at a threshold of €22,000/QALY. The mean ICER for medical admissions was €10,700/QALY (p = 97%), €12,300/QALY (p = 93%) for admissions after acute surgery, and €14,700/QALY (p = 84%) after planned surgery. For individualized ICERs, there was a 50% probability that ICU admission was cost-effective for 85% of the patients at a threshold of €64,000/QALY, leaving 15% of the admissions not cost-effective. In the distributional evaluation, 8% of all patients had distribution-weighted ICERs (higher weights to gains for more severe conditions) above €64,000/QALY. High-severity admissions gained the most, and were more cost-effective. CONCLUSIONS On average, ICU admission versus general ward care was cost-effective at a threshold of €22,000/QALY (p = 95%). According to the individualized cost-effectiveness information, one in six ICU admissions was not cost-effective at a threshold of €64,000/QALY. Almost half of these admissions that were not cost-effective can be regarded as acceptable when weighted by severity of disease in terms of expected lifetime health. Overall, existing ICU services represent reasonable resource use, but considerable uncertainty becomes evident when disaggregating into individualized results.
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Affiliation(s)
- Frode Lindemark
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Øystein A. Haaland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Reidar Kvåle
- Norwegian Intensive Care Registry, Helse Bergen HF, Bergen, Norway
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Hans Flaatten
- Norwegian Intensive Care Registry, Helse Bergen HF, Bergen, Norway
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ole F. Norheim
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Kjell A. Johansson
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Weinreich MA, Styrvoky K, Chang S, Girod CE, Ruggiero R. Sepsis at a Safety Net Hospital: Risk Factors Associated With 30-Day Readmission. J Intensive Care Med 2017; 34:1017-1022. [PMID: 28820039 DOI: 10.1177/0885066617726753] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sepsis is a leading cause of hospitalization, and subsequent readmissions are frequent and costly. There is an expanding body of literature describing risk factors for readmissions in patients with sepsis. However, there are little data studying medically underserved patients who typically receive their care at a safety net hospital. METHODS In a retrospective cohort study, we evaluated 1355 sepsis survivors at risk of hospital readmission in fiscal year 2013 at a safety net hospital. We described patient characteristics during their initial and readmission hospitalizations and analyzed risk factors associated with 30-day readmission. RESULTS The 30-day readmission rate among sepsis survivors was 22.6%. Comorbid conditions associated with readmissions included end-stage renal disease (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.17-1.36), malignancy (OR, 1.14; 95% CI, 1.08-1.21), and cirrhosis (OR, 1.11; 95% CI, 1.02-1.20). Bacteremia during the initial hospitalization (OR, 1.07; 95% CI, 1.01-1.15) and being discharged with a vascular catheter (OR, 1.10; 95% CI, 1.01-1.20) were associated with readmission. Less severe sepsis during the initial hospitalization was associated with a reduced risk of 30-day readmission (OR, 0.91; 95% CI, 0.87-0.94). CONCLUSIONS At a safety net hospital, patients who survived their initial sepsis hospitalization had a 30-day readmission rate to our institution of 22.6% that is comparable to rates described in prior studies. Readmission was commonly due to infection. Factors associated with readmission included multiple comorbid medical conditions, bacteremia, and being discharged with a vascular catheter. Further studies in this population are needed to determine potential modifiability of these risk factors in an attempt to reduce sepsis readmissions.
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Affiliation(s)
- Mark A Weinreich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kim Styrvoky
- Division of Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shelley Chang
- Parkland Center for Clinical Innovation, Dallas, TX, USA
| | - Carlos E Girod
- Division of Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Rosechelle Ruggiero
- Division of Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX, USA
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Zorio V, Venet F, Delwarde B, Floccard B, Marcotte G, Textoris J, Monneret G, Rimmelé T. Assessment of sepsis-induced immunosuppression at ICU discharge and 6 months after ICU discharge. Ann Intensive Care 2017; 7:80. [PMID: 28770544 PMCID: PMC5540741 DOI: 10.1186/s13613-017-0304-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 07/23/2017] [Indexed: 12/29/2022] Open
Abstract
Background Increase in mortality and in recurrent infections in the year following ICU discharge continues in survivors of septic shock, even after total clinical recovery from the initial septic event and its complications. This supports the hypothesis that sepsis could induce persistent long-term immune dysfunctions. To date, there is almost no data on ICU discharge and long-term evolution of sepsis-induced immunosuppression in septic shock survivors. The aim of this study was to assess the persistence of sepsis-induced immunosuppression by measuring expression of human leukocyte antigen DR on monocytes (mHLA-DR), CD4+ T cells, and regulatory T cells (Treg) at ICU discharge and 6 months after ICU discharge in patients admitted to the ICU for septic shock. Methods In this prospective observational study, septic shock survivors with no preexisting immune suppression or treatment interfering with the immune system were included. mHLA-DR, CD4+ T cells, and Treg expression were assessed on day 1–2, 3–4, and 6–8 after ICU admission, at ICU discharge, and 6 months after ICU discharge. Results A total of 40 patients were enrolled during their ICU stay: 21 males (52.5%) and 19 females, median age 68 years (IQR 58–77), median SOFA score on day 1–2 was 8 (IQR 7–9), and median ICU length of stay was 11 days (IQR 7–24). Among these 40 patients, 33 were studied at ICU discharge and 15 were disposed for blood sampling 6 months after ICU discharge. On day 1–2, mHLA-DR expression was abnormally low for all patients [median 4212 (IQR 2640–6047) AB/C] and remained abnormally low at ICU discharge for 75% of them [median 10,281 (IQR 7719–13,035) AB/C]. On day 3–4, 46% of patients presented CD4+ lymphopenia [median 515 (IQR 343–724) mm−3] versus 34% at ICU discharge [median 642 (IQR 459–846) mm−3]. Among patients with a 6-month blood sample, normal values of mHLA-DR were found for all patients [median 32,616 (IQR 24,918–38,738) AB/C] except for one and only another one presented CD4+ lymphopenia. Conclusions While immune alterations persist at ICU discharge, there is, at cellular level, no persistent immune alterations among septic shock survivors analyzed 6 months after ICU discharge.
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Affiliation(s)
- Violette Zorio
- Department of Anesthesiology and Critical Care Medicine, Edouard Herriot hospital, Hospices Civils de Lyon, Lyon, France. .,EA7426 Hospices Civils de Lyon - bioMérieux, University Claude Bernard Lyon 1 "Pathophysiology of Injury Induced Immunosuppression", Lyon, France.
| | - Fabienne Venet
- EA7426 Hospices Civils de Lyon - bioMérieux, University Claude Bernard Lyon 1 "Pathophysiology of Injury Induced Immunosuppression", Lyon, France.,Cellular Immunology Laboratory, Edouard Herriot hospital, Hospices Civils de Lyon, Lyon, France
| | - Benjamin Delwarde
- Department of Anesthesiology and Critical Care Medicine, Edouard Herriot hospital, Hospices Civils de Lyon, Lyon, France.,EA7426 Hospices Civils de Lyon - bioMérieux, University Claude Bernard Lyon 1 "Pathophysiology of Injury Induced Immunosuppression", Lyon, France
| | - Bernard Floccard
- Department of Anesthesiology and Critical Care Medicine, Edouard Herriot hospital, Hospices Civils de Lyon, Lyon, France
| | - Guillaume Marcotte
- Department of Anesthesiology and Critical Care Medicine, Edouard Herriot hospital, Hospices Civils de Lyon, Lyon, France
| | - Julien Textoris
- Department of Anesthesiology and Critical Care Medicine, Edouard Herriot hospital, Hospices Civils de Lyon, Lyon, France.,EA7426 Hospices Civils de Lyon - bioMérieux, University Claude Bernard Lyon 1 "Pathophysiology of Injury Induced Immunosuppression", Lyon, France
| | - Guillaume Monneret
- EA7426 Hospices Civils de Lyon - bioMérieux, University Claude Bernard Lyon 1 "Pathophysiology of Injury Induced Immunosuppression", Lyon, France.,Cellular Immunology Laboratory, Edouard Herriot hospital, Hospices Civils de Lyon, Lyon, France
| | - Thomas Rimmelé
- Department of Anesthesiology and Critical Care Medicine, Edouard Herriot hospital, Hospices Civils de Lyon, Lyon, France.,EA7426 Hospices Civils de Lyon - bioMérieux, University Claude Bernard Lyon 1 "Pathophysiology of Injury Induced Immunosuppression", Lyon, France
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The long-term burden of severe sepsis and septic shock: Sepsis recidivism and organ dysfunction. J Trauma Acute Care Surg 2017; 81:525-32. [PMID: 27398984 DOI: 10.1097/ta.0000000000001135] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe sepsis and septic shock mortality has improved; however, rates of persistent (28-90 days) and long-term (>90 day) organ dysfunction in sepsis survivors are unknown. METHODS Secondary analysis of a prospective cohort of adult emergency department patients with severe sepsis. RESULTS Of 110 sepsis admissions, we obtained follow-up on 51 of 78 survivors of whom 41% (21 of 51) had persistent organ dysfunction: pulmonary, 18% (9 of 51); renal, 22% (11 of 51); coagulopathy, 10% (5 of 51); cardiovascular, 6% (3 of 51); hepatic, 2% (1 of 51); and neurologic, 3% (3 of 51). We obtained follow-up on 40 of 73 survivors at more than 90 days of whom 38% (15 of 40) had long-term organ dysfunction: pulmonary, 13% (5 of 40); renal, 18% (7 of 40); coagulopathy, 3% (1 of 40); cardiovascular, 5% (2 of 40); hepatic, 0%; and neurologic, 5% (2 of 40). Readmission rate within 90 days was 32% (25 of 78), and recurrent sepsis was the cause of readmission in 52% (13 of 25). Baseline SOFA scores from the index sepsis admission were compared using Wilcoxon rank-sum test and were significantly different in participants with organ dysfunction versus those without organ dysfunction at less than 90 days (z, -2.51; p = 0.01). CONCLUSION Readmission with recurrent sepsis and organ dysfunction occurs frequently in sepsis survivors. Baseline SOFA score may be predictive of sepsis recidivism and persistent or recurrent organ dysfunction. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level IV.
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