Postdischarge Survival After Sepsis: A Cohort Study

BACKGROUND

After hospital discharge, patients who had sepsis have increased mortality. We sought to estimate factors associated with postdischarge mortality and how they vary with time after discharge.

METHODS

This was a retrospective study of hospital survivors of sepsis using time-varying Cox proportional hazard models, which produce a baseline hazard ratio (HR) and a second number (δHR) that reflects the amount by which the baseline HR changes with time.

RESULTS

Of the 32,244 patients who survived sepsis at hospital discharge, 13,565 patients (42%) died (mean ± standard deviation: 1.41 ± 1.87 years) after discharge from the index hospitalization, while 18,679 patients were still alive at follow-up (4.98 ± 2.86 years). The mortality rate decreased with time after discharge: approximately 8.7% of patients died during the first month after discharge, 1.1% of patients died during the 12th month after discharge, and 0.3%% died during the 60th month; after Kaplan-Meier analysis, survival was 91% (95% confidence interval [CI], 91%-92%) at 1 month, 76% (95% CI, 76%-77%) at 1 year, 57% (95% CI, 56%-58%) at 5 years, and 48% (95% CI, 47%-48%) at 10 years after discharge. Organ dysfunction at discharge was associated with worse survival. In particular, elevated urea nitrogen at discharge (HR, 1.10 per 10 mg/dL, 95% CI, 1.08-1.12, P < .001) was associated with increased mortality, but the HR decreased with time from discharge (δHR, 0.98 per 10 mg/dL per year, 95% CI, 0.98-0.99, P < .001). Higher hemoglobin levels were associated with lower mortality (HR, 0.92 per g/dL, 95% CI, 0.91-0.93, P < .001), but this association increased with increasing time after discharge (δHR, 1.02 per g/dL per year, 95% CI, 1.01-1.02, P < .001). Older age was associated with an increased risk of mortality (HR, 1.29 per decade of age, 95% CI, 1.27-1.31, P < .001) that grew with increasing time after discharge (δHR, 1.01 per year of follow-up per decade of age, 95% CI, 1.00-1.02, P < .001). Compared to private insurances Medicaid as primary insurance was associated with an increased risk of mortality (HR, 1.17, 95% CI, 1.10-1.25, P < .001) that did not change with time after discharge. In contrast, Medicare status was initially associated with a similar risk of mortality as private insurance at discharge (HR, 1), but was associated with greater risk as time after discharge increased (δHR, 1.04 per year of follow-up, 95% CI, 1.03-1.05, P < .001).

CONCLUSIONS

Acute physiologic derangements and organ dysfunction were associated with postdischarge mortality with the associations decreasing over time.

Buffered Lidocaine as an Endotracheal Tube Cuff Media In Immediate Postoperative Cardiac Surgery Patients And Its Effect On Sedation Requirements: A Prospective Feasibility Study

Tracheal mucosal inflammation and irritation caused by the endotracheal tube (ETT) may exacerbate symptoms of pain and discomfort which create challenges including ETT tolerance and postintubation emergence phenomena. Various sedative and analgesic agents are used to mitigate these symptoms, however, there is concern that such medications may contribute to prolonged duration of intubation, length of intensive care unit (ICU) stay, as well as increased morbidity. This randomized control pilot study explored the feasibility and potential efficacy of instillation of a buffered lidocaine solution as an ETT cuff medium in adult rapid recovery eligible cardiac surgical patients. Thirty-two patients were randomized to the intervention (1.8% lidocaine/0.76% sodium bicarbonate) or control (air) group. Data were analyzed using median, standard deviation (SD), Wilcoxon rank sum, mean ± SD, two-sample t-test, and Fisher's exact test. The intervention arm demonstrated a trend toward a reduction in the incidence of cough at ICU arrival (0 versus 22%), incidence of pharyngitis at all time intervals, and propofol requirement (345 ± 248 mg versus 1,158 ± 1,426 mg) with no difference in adverse events between groups. These results support the development of larger studies to confirm the efficacy and feasibility of buffered lidocaine as an ETT cuff medium in this population.