Hyperoxemia in postsurgical sepsis/septic shock patients is associated with reduced mortality

Abstract Background Despite growing interest in treatment strategies that limit oxygen exposure in ICU patients, no studies have compared conservative oxygen with standard oxygen in postsurgical patients with sepsis/septic shock, although there are indications that it may improve outcomes. It has been proven that high partial pressure of oxygen in arterial blood (PaO2) reduces the rate of surgical-wound infections and mortality in patients under major surgery. The aim of this study is to examine whether PaO2 is associated with risk of death in adult patients with sepsis/septic shock after major surgery. Methods We performed a secondary analysis of a prospective observational study in 454 patients who underwent major surgery admitted into a single ICU. Patients were stratified in two groups whether they had hyperoxemia, defined as PaO2 > 100 mmHg (n = 216), or PaO2 ≤ 100 mmHg (n = 238) at the day of sepsis/septic shock onset according to SEPSIS-3 criteria maintained during 48 h. Primary end-point was 90-day mortality after diagnosis of sepsis. Secondary endpoints were ICU length of stay and time to extubation. Results In patients with PaO2 ≤ 100 mmHg, we found prolonged mechanical ventilation (2 [8] vs. 1 [4] days, p < 0.001), higher ICU stay (8 [13] vs. 5 [9] days, p < 0.001), higher organ dysfunction as assessed by SOFA score (9 [3] vs. 7 [5], p < 0.001), higher prevalence of septic shock (200/238, 84.0% vs 145/216) 67.1%, p < 0.001), and higher 90-day mortality (37.0% [88] vs. 25.5% [55], p = 0.008). Hyperoxemia was associated with higher probability of 90-day survival in a multivariate analysis (OR 0.61, 95%CI: 0.39–0.95, p = 0.029), independent of age, chronic renal failure, procalcitonin levels, and APACHE II score > 19. These findings were confirmed when patients with severe hypoxemia at the time of study inclusion were excluded. Conclusions Oxygenation with a PaO2 above 100 mmHg was independently associated with lower 90-day mortality, shorter ICU stay and intubation time in critically ill postsurgical sepsis/septic shock patients. Our findings open a new venue for designing clinical trials to evaluate the boundaries of PaO2 in postsurgical patients with severe infections.

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The Relationship of the ACCP/SCCM Consensus Conference Classification of Sepsis to Mortality and Multiorgan Dysfunction among Medical ICU Patients

Journal of Intensive Care Medicine ◽

10.1177/088506669601100604 ◽

1996 ◽

Vol 11 (6) ◽

pp. 326-334 ◽

Cited By ~ 4

Author(s):

Marin H. Kollef ◽

Paul R. Eisenberg

Keyword(s):

Septic Shock ◽

Severe Sepsis ◽

Hospital Mortality ◽

Consensus Conference ◽

Organ System ◽

Apache Ii ◽

Apache Ii Score ◽

Icu Patients ◽

Multiorgan Dysfunction

To determine the relation between the proposed ACCP/SCCM Consensus Conference classification of sepsis and hospital outcomes, we conducted a single-center, prospective observational study at Barnes Hospital, St. Louis, MO, an academic tertiary care hospital. A total of 324 consecutive patients admitted to the medical intensive care unit (ICU) were studied for prospective patient surveillance and data collection. The main outcome measures were the number of acquired organ system derangements and hospital mortality. Fifty-seven (17.6%) patients died during the study period. The proposed classifications of sepsis (e.g., systemic inflammatory response syndrome [SIRS], sepsis, severe sepsis, septic shock) correlated with hospital mortality ( r = 0.330; p < 0.001) and development of an Organ System Failure Index (OSFI) of 3 or greater ( r = 0.426; p < 0.001). Independent determinants of hospital mortality for this patient cohort ( p < 0.05) were development of an OSFI of 3 or greater (adjusted odds ratio [AOR], 13.9; 95% confidence interval [CI], 6.4–30.2; p < 0.001); presence of severe sepsis or septic shock (AOR, 2.6; 95% CI, 1.2–5.6; p = 0.002), and an APACHE II score ≥ of 18 or greater (AOR, 2.4; 95% CI, 1.0–5.8; p = 0.045). Intra-abdominal infection (AOR, 19.1; 95% CI, 1.6–230.1; p = 0.011), an APACHE II score ≥ of 18 or greater (AOR, 8.9; 95% CI, 4.2–18.6; p < 0.001), and presence of severe sepsis or septic shock (AOR, 2.9; 95% CI, 1.5–5.4; p = 0.001) were independently associated with development of an OSFI of 3 or greater. These data confirm that acquired multiorgan dysfunction is the most important predictor of mortality among medical ICU patients. In addition, they identify the proposed ACCP/SCCM Consensus Conference classification of sepsis as an additional independent determinant of both hospital mortality and multiorgan dysfunction.

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Using survival analysis to predict septic shock onset in ICU patients

Journal of Critical Care ◽

10.1016/j.jcrc.2018.08.041 ◽

2018 ◽

Vol 48 ◽

pp. 339-344

Author(s):

Benjamin Dummitt ◽

Angelique Zeringue ◽

Ashok Palagiri ◽

Christopher Veremakis ◽

Benjamin Burch ◽

...

Keyword(s):

Septic Shock ◽

Survival Analysis ◽

Shock Onset ◽

Icu Patients

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TNFAIP3, TNIP1, and MyD88 Polymorphisms Predict Septic-Shock-Related Death in Patients Who Underwent Major Surgery

Journal of Clinical Medicine ◽

10.3390/jcm8030283 ◽

2019 ◽

Vol 8 (3) ◽

pp. 283 ◽

Cited By ~ 1

Author(s):

Maria Jiménez-Sousa ◽

Alejandra Fadrique ◽

Pilar Liu ◽

Amanda Fernández-Rodríguez ◽

Mario Lorenzo-López ◽

...

Keyword(s):

Septic Shock ◽

Signaling Pathway ◽

Haplotype Analysis ◽

Case Control Study ◽

Inflammatory Responses ◽

Major Surgery ◽

Susceptibility To Infection ◽

Risk Of Death ◽

First 90 Days ◽

Control Study

Background: In many immune-related diseases, inflammatory responses and several clinical outcomes are related to increased NF-κB activity. We aimed to evaluate whether SNPs related to the NF-κB signaling pathway are associated with higher susceptibility to infection, septic shock, and septic-shock-related death in European patients who underwent major surgery. Methods: We performed a case-control study on 184 patients with septic shock and 212 with systemic inflammatory response syndrome, and a longitudinal substudy on septic shock patients. Thirty-three SNPs within genes belonging to or regulating the NF-κB signaling pathway were genotyped by Agena Bioscience’s MassARRAY platform. Results: No significant results were found for susceptibility to infection and septic shock in the multivariate analysis after adjusting for multiple comparisons. Regarding septic-shock-related death, patients with TNFAIP3 rs6920220 AA, TNIP1 rs73272842 AA, TNIP1 rs3792783 GG, and TNIP1 rs7708392 CC genotypes had the highest risk of septic-shock-related death in the first 28 and 90 days. Also, the MyD88 rs7744 GG genotype was associated with a higher risk of death during the first 90 days. Haplotype analysis shows us that patients with the TNIP1 GAG haplotype (composed of rs73272842, rs3792783, and rs7708392) had a lower risk of death in the first 28 days and the TNIP1 AGC haplotype was associated with a higher risk of death in the first 90 days. Conclusions: The SNPs in the genes TNFAIP3, TNIP1, and MyD88 were linked to the risk of septic-shock-related death in patients who underwent major surgery.

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Protein carbonyl concentration as a biomarker for development and mortality in sepsis-induced acute kidney injury

Bioscience Reports ◽

10.1042/bsr20171238 ◽

2018 ◽

Vol 38 (1) ◽

Cited By ~ 6

Author(s):

Nara Aline Costa ◽

Ana Lúcia Gut ◽

Paula Schmidt Azevedo ◽

Suzana Erico Tanni ◽

Natália Baraldi Cunha ◽

...

Keyword(s):

Septic Shock ◽

Prospective Observational Study ◽

Kidney Injury ◽

Protein Carbonyl ◽

Apache Ii Score ◽

Roc Curve Analysis ◽

Logistic Regression Models ◽

Icu Admission ◽

Icu Stay ◽

The Mean

The objective of the present study was to evaluate protein carbonyl concentration as a predictor of AKI development in patients with septic shock and of renal replacement therapy (RRT) and mortality in patients with SAKI. This was a prospective observational study of 175 consecutive patients over the age of 18 years with septic shock upon Intensive Care Unit (ICU) admission. After exclusion of 46 patients (27 due to AKI at ICU admission), a total of 129 patients were enrolled in the study. Demographic information and blood samples were taken within the first 24 h of the patient’s admission to determine serum protein carbonyl concentrations. Among the patients who developed SAKI, the development of AKI was evaluated, along with mortality and need for RRT. The mean age of the patients was 63.3 ± 15.7 years, 47% were male and 51.2% developed SAKI during ICU stay. In addition, protein carbonyl concentration was shown to be associated with SAKI. Among 66 patients with SAKI, 77% died during the ICU stay. Protein carbonyl concentration was not associated with RRT in patients with SAKI. However, the ROC curve analysis revealed that higher levels of protein carbonyl were associated with mortality in these patients. In logistic regression models, protein carbonyl level was associated with SAKI development (OR: 1.416; 95% CI: 1.247–1.609; P<0.001) and mortality when adjusted by age, gender, and APACHE II score (OR: 1.357; 95% CI: 1.147–1.605; P<0.001). In conclusion, protein carbonyl concentration is predictive of AKI development and mortality in patients with SAKI, with excellent reliability.

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Low triiodothyronine (T3) state: a predictor of outcome in respiratory failure? Results of a clinical pilot study

Acta Endocrinologica ◽

10.1530/eje.0.1510557 ◽

2004 ◽

pp. 557-560 ◽

Cited By ~ 49

Author(s):

E Scoscia ◽

S Baglioni ◽

A Eslami ◽

G Iervasi ◽

S Monti ◽

...

Keyword(s):

Respiratory Failure ◽

Thyroid Function ◽

Plasma Levels ◽

Apache Ii ◽

Apache Ii Score ◽

Univariate Logistic Regression Analysis ◽

Risk Of Death ◽

Arterial Blood ◽

Low T3 ◽

Increased Risk

BACKGROUND AND AIM: Various low triiodothyronine (T3) states have been described in severe nonthyroidal diseases and associated with a poor prognosis in cardiovascular disease patients. We assessed thyroid function in patients with severe respiratory failure from pulmonary disorders, and needing invasive or noninvasive mechanical ventilation, in order to evaluate the prognostic value of nonthyroidal illness syndrome. METHODS: We studied 32 consecutive patients with acute or acute-on-chronic respiratory failure. Measured variables upon admission included APACHE II score, the ratio of the partial pressure of oxygen in arterial blood to the fraction of oxygen in inspired gas (PaO(2)/FiO(2)), and plasma levels of free T3 (fT3) and free thyroxine (fT4), and TSH levels. Thyroid function was further evaluated at discharge. RESULTS: Plasma levels of fT3 were below normal in 17 patients (53%). Plasma fT3 was correlated with PaO(2)/FiO(2) (P<0.001), and with APACHE II score (P=0.003). In four patients (12.5%) who died, fT3 levels were significantly lower (P=0.002) than in patients who survived. In univariate logistic regression analysis, fT3 was the only factor significantly associated with an increased risk of death (odds ratio, 64.23; 95% confidence interval, 1.78-2316.86, P=0.023). Normalization of thyroid function was observed at discharge with a significant correlation between the percent increase in both fT3 and PaO(2)/FiO(2) (P=0.015). P values were calculated using Spearman's Correlation Coefficient. CONCLUSION: Our preliminary data suggest that the low T3 state is a predictor of outcome in pulmonary patients with respiratory failure.

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Thoracic skeletal muscle quantification using computed tomography and prognosis of elderly ICU patients

Scientific Reports ◽

10.1038/s41598-021-02853-4 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Sung Woo Moon ◽

Song Yee Kim ◽

Ji Soo Choi ◽

Ah Young Leem ◽

Su Hwan Lee ◽

...

Keyword(s):

Skeletal Muscle ◽

Prolonged Mechanical Ventilation ◽

Significant Risk ◽

Pectoralis Muscle ◽

Muscle Loss ◽

Icu Patients ◽

Icu Admission ◽

Icu Stay ◽

Prolonged Ventilation ◽

Skeletal Muscle Loss

AbstractIn elderly ICU patients, the prevalence of skeletal muscle loss is high. Longitudinal effect of thoracic muscles, especially in elderly ICU patients, are unclear although skeletal muscle loss is related with the short- and long-term outcomes. This study aimed to evaluate whether pectoralis muscle mass loss could be a predictor of prognosis in elderly ICU patients. We retrospectively evaluated 190 elderly (age > 70 years) patients admitted to the ICU. We measured the cross-sectional area (CSA) of the pectoralis muscle (PMCSA) at the fourth vertebral region. CT scans within two days before ICU admission were used for analysis. Mortality, prolonged mechanical ventilation, and longitudinal changes in Sequential Organ Failure Assessment (SOFA) scores were examined. PMCSA below median was significantly related with prolonged ventilation (odds ratio 2.92) and a higher SOFA scores during the ICU stay (estimated mean = 0.94). PMCSA below median was a significant risk for hospital mortality (hazards ratio 2.06). In elderly ICU patients, a low ICU admission PMCSA was associated with prolonged ventilation, higher SOFA score during the ICU stay, and higher mortality. Adding thoracic skeletal muscle CSA at the time of ICU admission into consideration in deciding the therapeutic intensity in elderly ICU patients may help in making medical decisions.

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Clinical Outcome of Urgent Thoracotomy in Patients with Penetrating and Blunt Chest Trauma: A Retrospective Survey

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0037-1608899 ◽

2017 ◽

Vol 66 (08) ◽

pp. 686-692

Author(s):

Yael Refaely ◽

Leonid Koyfman ◽

Michael Friger ◽

Leonid Ruderman ◽

Mahmud Saleh ◽

...

Keyword(s):

Blunt Chest Trauma ◽

Chest Trauma ◽

Injury Severity ◽

Penetrating Trauma ◽

Apache Ii Score ◽

Thoracic Injuries ◽

Icu Stay ◽

Chest Injuries ◽

Arterial Blood ◽

Trauma Group

Introduction In contrast to an emergency department of thoracotomy (EDT), an urgent thoracotomy (UT) is defined as a surgical thoracic intervention performed in the operating room within the first 48 hours of the patient's intensive care unit (ICU) stay. The factors affecting survival after UT are not fully understood. In this study, we retrospectively analyzed the clinical data and outcome of patients with blunt and penetrating chest injuries who underwent UT. Methods All adult patients who had blunt or penetrating chest trauma and who underwent UT, were included in the study. All data were collected from the patients' hospital and ICU records. Forty-five patients with thoracic injuries who underwent UT during the first 48 hours of ICU stay were analyzed. Of these, 25 had penetrating chest injuries, and 20 had blunt thoracic injuries. Of the penetrating injuries, 16 were stab wounds, and 9 were gunshot wounds. Results Overall ICU mortality was 29% (n = 13) and was significantly higher in the blunt chest trauma group than in the penetrating trauma group (45% vs 16%; p = 0.04). Lung parenchyma injuries (lacerations and contusions) were the most common intraoperative findings in both groups. The following independent predictors of in-hospital mortality were found: an Injury Severity Score (ISS) of >40; an Acute Physiology and Chronic Evaluation II (APACHE II) score of >30; prolonged duration of UT; low body temperature on admission to the ED; abnormal arterial blood lactate, bicarbonate, and pH at the end of UT; and use of vasopressors during the first 24 hours of ICU stay. Conclusion Mortality after UT was higher in patients with blunt chest trauma. The UT should be performed in both penetrating and blunt chest trauma as quickly as possible and should be limited to damage control. It also emerges that acidosis and hypothermia in chest trauma patients need to be treated extremely aggressively before, during, and after UT.

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Early Improvement of Acute Respiratory Distress Syndrome in Patients with COVID-19: Insights from the Data of ICU Patients in Chongqing, China (Preprint)

10.2196/preprints.24843 ◽

2020 ◽

Author(s):

Zhu Zhan ◽

Xin Yang ◽

Hu Du ◽

Chuanlai Zhang ◽

Yuyan Song ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Case Fatality ◽

Bivariate Analysis ◽

Icu Patients ◽

Early Improvement ◽

Icu Stay ◽

Arterial Blood

UNSTRUCTURED Background: This study aimed to describe the clinical features, outcomes, and acute respiratory distress syndrome (ARDS) characteristics of patients with coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU) in Chongqing, China. Methods: The epidemiology of COVID-19 in Chongqing, China, was analyzed retrospectively, and 75 ICU patients from 2 hospitals were included in this study. On day 1, 56 patients with ARDS were selected for subgroup analysis, and bivariate analysis was performed to identify predictors for early improvement of ARDS (eiARDS). Results: Chongqing reported a 5.3% case fatality rate of the 75 ICU patients. The median age of the ICU patients was 57 years (interquartile range, 25–75), and no bias was obtained in the sex ratio. A total of 93% of patients developed ARDS during ICU stay, and more than half had moderate ARDS. However, most of the patients (55%) were supported with high-flow nasal cannula oxygen therapy, but not mechanical ventilation. Nearly one third of patients with ARDS improved (arterial blood oxygen partial pressure/oxygen concentration >300 mm Hg) in 1 week, which was defined as eiARDS. Patients with eiARDS had a higher survival rate and lower length of ICU stay than those with “non-eiARDS”. Age (<55 years) was the only variable independently associated with eiARDS, with an odds ratio of 7.4. Conclusions: eiARDS was common in patients with COVID-19, and predicted a favorable clinical outcome. Age (<55 years) was an independent predictor of eiARDS, and stratification of patients with COVID-19 by age was recommended.

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Change in diaphragm and intercostal muscle thickness in mechanically ventilated patients: a prospective observational ultrasonography study

Journal of Intensive Care ◽

10.1186/s40560-019-0410-4 ◽

2019 ◽

Vol 7 (1) ◽

Cited By ~ 7

Author(s):

Nobuto Nakanishi ◽

Jun Oto ◽

Yoshitoyo Ueno ◽

Emiko Nakataki ◽

Taiga Itagaki ◽

...

Keyword(s):

Mechanical Ventilation ◽

Prolonged Mechanical Ventilation ◽

Muscle Thickness ◽

Apache Ii Score ◽

Intercostal Muscle ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

Icu Stay ◽

Length Of Icu Stay ◽

Ventilated Patients

Abstract Background Diaphragm atrophy is observed in mechanically ventilated patients. However, the atrophy is not investigated in other respiratory muscles. Therefore, we conducted a two-center prospective observational study to evaluate changes in diaphragm and intercostal muscle thickness in mechanically ventilated patients. Methods Consecutive adult patients who were expected to be mechanically ventilated longer than 48 h in the ICU were enrolled. Diaphragm and intercostal muscle thickness were measured on days 1, 3, 5, and 7 with ultrasonography. The primary outcome was the direction of change in muscle thickness, and the secondary outcomes were the relationship of changes in muscle thickness with patient characteristics. Results Eighty patients (54 males and 26 females; mean age, 68 ± 14 years) were enrolled. Diaphragm muscle thickness decreased, increased, and remained unchanged in 50 (63%), 15 (19%), and 15 (19%) patients, respectively. Intercostal muscle thickness decreased, increased, and remained unchanged in 48 (60%), 15 (19%), and 17 (21%) patients, respectively. Decreased diaphragm or intercostal muscle thickness was associated with prolonged mechanical ventilation (median difference (MD), 3 days; 95% CI (confidence interval), 1–7 and MD, 3 days; 95% CI, 1–7, respectively) and length of ICU stay (MD, 3 days; 95% CI, 1–7 and MD, 3 days; 95% CI, 1–7, respectively) compared with the unchanged group. After adjusting for sex, age, and APACHE II score, they were still associated with prolonged mechanical ventilation (hazard ratio (HR), 4.19; 95% CI, 2.14–7.93 and HR, 2.87; 95% CI, 1.53–5.21, respectively) and length of ICU stay (HR, 3.44; 95% CI, 1.77–6.45 and HR, 2.58; 95% CI, 1.39–4.63, respectively) compared with the unchanged group. Conclusions Decreased diaphragm and intercostal muscle thickness were frequently seen in patients under mechanical ventilation. They were associated with prolonged mechanical ventilation and length of ICU stay. Trial registration UMIN000031316. Registered on 15 February 2018

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Early Improvement of Acute Respiratory Distress Syndrome in Patients With COVID-19 in the Intensive Care Unit: Retrospective Analysis

JMIR Public Health and Surveillance ◽

10.2196/24843 ◽

2021 ◽

Vol 7 (3) ◽

pp. e24843

Author(s):

Zhu Zhan ◽

Xin Yang ◽

Hu Du ◽

Chuanlai Zhang ◽

Yuyan Song ◽

...

Keyword(s):

Intensive Care Unit ◽

Acute Respiratory Distress Syndrome ◽

Intensive Care ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Icu Patients ◽

Early Improvement ◽

Icu Stay ◽

Arterial Blood

Background Since the start of the COVID-19 pandemic, there have been over 2 million deaths globally. Acute respiratory distress syndrome (ARDS) may be the main cause of death. Objective This study aimed to describe the clinical features, outcomes, and ARDS characteristics of patients with COVID-19 admitted to the intensive care unit (ICU) in Chongqing, China. Methods The epidemiology of COVID-19 from January 21, 2020, to March 15, 2020, in Chongqing, China, was analyzed retrospectively, and 75 ICU patients from two hospitals were included in this study. On day 1, 56 patients with ARDS were selected for subgroup analysis, and a modified Poisson regression was performed to identify predictors for the early improvement of ARDS (eiARDS). Results Chongqing reported a 5.3% case fatality rate for the 75 ICU patients. The median age of these patients was 57 (IQR 25-75) years, and no bias was present in the sex ratio. A total of 93% (n=70) of patients developed ARDS during ICU stay, and more than half had moderate ARDS. However, most patients (n=41, 55%) underwent high-flow nasal cannula oxygen therapy, but not mechanical ventilation. Nearly one-third of patients with ARDS improved (arterial blood oxygen partial pressure/oxygen concentration >300 mm Hg) in 1 week, which was defined as eiARDS. Patients with eiARDS had a higher survival rate and a shorter length of ICU stay than those without eiARDS. Age (<55 years) was the only variable independently associated with eiARDS, with a risk ratio of 2.67 (95% CI 1.17-6.08). Conclusions A new subphenotype of ARDS—eiARDS—in patients with COVID-19 was identified. As clinical outcomes differ, the stratified management of patients based on eiARDS or age is highly recommended.

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