Current Epidemiology of Surgical Sepsis Discordance Between Inpatient Mortality and 1-year Outcomes
Current Epidemiology of Surgical Sepsis Discordance Between Inpatient Mortality and 1-year Outcomes
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DOI：
10.1097/sla.0000000000003458
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发表时间：
2019-09-01
影响因子：
9
通讯作者：
Moore, Frederick A.
中科院分区：
文献类型：
--
作者：
Brakenridge, Scott C.;Efron, Philip A.;Moore, Frederick A.
目的：我们试图比较传统的住院预后与长期功能预后以及外科重症监护室（SICU）脓毒症患者的死亡率。背景数据总结：随着住院脓毒症死亡率的下降，越来越多的初始脓毒症幸存者现在进展为慢性危重病（CCI）状态，其出院后结局尚不清楚。方法：我们对SICU脓毒症患者进行了一项前瞻性、纵向队列研究。结果：在最近的301例脓毒症SICU患者队列中，30天死亡率为9.6%。只有13例（4%）患者在14天内死亡，主要是难治性多器官衰竭（62%）。大多数（n = 189，63%）表现出快速恢复（RAP），而99（33%）发展CCI。CCI患者年龄较大，合并症较多，器官功能障碍较RAP患者严重和持续（均P < 0.01）。在12个月时，整个队列的体能状态持续低于术前基线（WHO/Zubrod评分1.4 +/- 0.08 vs 2.2 +/- 0.23，P > 0.0001），死亡率为20.9%。值得注意的是，在控制了年龄和合并症负担后，12个月时，CCI队列的体力状态持续严重受损，死亡率（41.4%）远高于RAP队列（4.8%）（考克斯风险比1.27; 95%置信区间，1.14-1.41，P < 0.0001）。在CCI患者中，12个月内死亡的独立危险因素包括合并症的严重程度和脓毒症发作后第14天持续的器官功能障碍（序贯器官衰竭评估>= 6）。结论：低住院死亡率和外科脓毒症后的不良长期结局之间存在不一致性，尤其是在老年人中，增加了合并症负担和发生CCI的患者。在讨论因败血症而经历复杂临床过程的手术患者的预期结局时，这是重要的信息。
Objective: We sought to compare traditional inpatient outcomes to long-term functional outcomes and mortality of surgical intensive care unit (SICU) patients with sepsis. Summary of Background Data: As inpatient sepsis mortality declines, an increasing number of initial sepsis survivors now progress into a state of chronic critical illness (CCI) and their post-discharge outcomes are unclear. Methods: We performed a prospective, longitudinal cohort study of SICU patients with sepsis. Results: Among this recent cohort of 301 septic SICU patients, 30-day mortality was 9.6%. Only 13 (4%) patients died within 14 days, primarily of refractory multiple organ failure (62%). The majority (n = 189, 63%) exhibited a rapid recovery (RAP), whereas 99 (33%) developed CCI. CCI patients were older, with greater comorbidities, and more severe and persistent organ dysfunction than RAP patients (all P < 0.01). At 12 months, overall cohort performance status was persistently worse than presepsis baseline (WHO/Zubrod score 1.4 +/- 0.08 vs 2.2 +/- 0.23, P > 0.0001) and mortality was 20.9%. Of note at 12 months, the CCI cohort had persistent severely impaired performance status and a much higher mortality (41.4%) than those with RAP (4.8%) after controlling for age and comorbidity burden (Cox hazard ratio 1.27; 95% confidence interval, 1.14-1.41, P < 0.0001). Among CCI patients, independent risk factors for death by 12 months included severity of comorbidities and persistent organ dysfunction (sequential organ failure assessment >= 6) at day 14 after sepsis onset. Conclusions: There is discordance between low inpatient mortality and poor long-term outcomes after surgical sepsis, especially among older adults, increasing comorbidity burden and patients that develop CCI. This represents important information when discussing expected outcomes of surgical patients who experience a complicated clinical course owing to sepsis.