Benchmarking clinical outcomes and the immunocatabolic phenotype of chronic critical illness after sepsis in surgical intensive care unit patients
Benchmarking clinical outcomes and the immunocatabolic phenotype of chronic critical illness after sepsis in surgical intensive care unit patients
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DOI：
10.1097/ta.0000000000001758
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发表时间：
2018-02-01
影响因子：
3.4
通讯作者：
Brakenridge, Scott C.
中科院分区：
文献类型：
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作者：
Stortz, Julie A.;Mira, Juan C.;Brakenridge, Scott C.
背景技术越来越多的脓毒症患者幸存下来，但仍处于慢性危重状态。我们试图定义脓毒症后慢性危重病 (CCI) 的临床结果和发生率，并确定这些患者与快速康复 (RAP) 患者之间选定的炎症、免疫抑制和分解代谢生物标志物是否存在差异。 方法 这项为期 3 年的前瞻性观察队列研究 (NCT02276417) 评估了 145 名外科重症监护病房脓毒症患者的发展情况。 CCI（持续器官功能障碍的重症监护病房资源利用 14 天）。收集患者临床人口统计数据、结果和连续血清/尿液样本，用于血浆蛋白和尿液代谢物分析。 结果 在纳入的 145 名脓毒症患者中，19 名（13%）在住院期间死亡，71 名（49%）发生 CCI。 CCI 患者年龄明显较大（平均 63±15 岁 vs. 58±13 岁，p = 0.006），更有可能出院到长期急性护理机构（32% vs. 3%，p < 0.0001），而 RAP 患者更常出院回家或康复机构。与 RAP 队列相比，CCI 组的 6 个月死亡率显着更高（37% vs. 2%；p < 0.01）。多变量逻辑回归模型显示迟发型脓毒症（入院后 >48 小时；比值比 [OR]，10.93；95% 置信区间 [CI]，4.15-28.82]）、跨机构转移（OR，3.58；95% CI，1.43-8.96）、血管加压药依赖性脓毒症休克（OR，3.75；95% CI， 1.47-9.54）和 72 小时时序贯器官衰竭评估评分为 5 或更高（OR，5.03；95% CI，2.00-12.62）作为发生 CCI 的独立危险因素。 CCI 患者的炎症细胞因子（IL-6、IL-8、IL-10）也表现出更高的升高，并且生物标志物谱与持续免疫抑制（绝对淋巴细胞计数和可溶性程序性死亡配体 1）和分解代谢（血浆胰岛素样生长因子结合蛋白 3 和尿 3-甲基组氨酸排泄）一致。 结论 CCI 的发展已成为脓毒症重症外科患者的主要临床轨迹。这些患者表现出的生物标志物特征与持续炎症、免疫抑制和分解代谢的免疫分解代谢表型一致。证据级别预后，II 级。
BACKGROUND A growing number of patients survive sepsis but remain chronically critically ill. We sought to define clinical outcomes and incidence of chronic critical illness (CCI) after sepsis and to determine whether selected biomarkers of inflammation, immunosuppression, and catabolism differ between these patients and those that rapidly recover (RAP).METHODS This 3-year prospective observational cohort study (NCT02276417) evaluated 145 surgical intensive care unit patients with sepsis for the development of CCI (14 days of intensive care unit resource utilization with persistent organ dysfunction). Patient clinical demographics, outcomes, and serial serum/urine samples were collected for plasma protein and urinary metabolite analyses.RESULTS Of 145 sepsis patients enrolled, 19 (13%) died during their hospitalization and 71 (49%) developed CCI. The CCI patients were significantly older (mean, 63 15 vs. 58 13 years, p = 0.006) and more likely to be discharged to long-term acute care facilities (32% vs. 3%, p < 0.0001), whereas those with RAP were more often discharged to home or a rehabilitation facility. Six-month mortality was significantly higher in CCI as compared with RAP cohort (37% vs. 2%; p < 0.01). Multivariate logistic regression modeling revealed delayed onset sepsis (>48 hours after admission; odds ratio [OR], 10.93; 95% confidence interval [CI], 4.15-28.82]), interfacility transfer (OR, 3.58; 95% CI, 1.43-8.96), vasopressor-dependent septic shock (OR, 3.75; 95% CI, 1.47-9.54), and Sequential Organ Failure Assessment score of 5 or greater at 72 hours (OR, 5.03; 95% CI, 2.00-12.62) as independent risk factors for the development of CCI. The CCI patients also demonstrated greater elevations in inflammatory cytokines (IL-6, IL-8, IL-10), and biomarker profiles are consistent with persistent immunosuppression (absolute lymphocyte count and soluble programmed death ligand 1) and catabolism (plasma insulin-like growth factor binding protein 3 and urinary 3-methylhistidine excretion).CONCLUSION The development of CCI has become the predominant clinical trajectory in critically ill surgical patients with sepsis. These patients exhibit biomarker profiles consistent with an immunocatabolic phenotype of persistent inflammation, immunosuppression, and catabolism.LEVEL OF EVIDENCE Prognostic, level II.