Survival in neutropenic patients with severe sepsis or septic shock
Survival in neutropenic patients with severe sepsis or septic shock
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DOI：
10.1097/ccm.0b013e31822b50c2
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发表时间：
2012-01-01
影响因子：
8.8
通讯作者：
Azoulay, Elie
中科院分区：
文献类型：
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作者：
Legrand, Matthieu;Max, Adeline;Azoulay, Elie
目的：探讨近年来癌症危重症患者中嗜中性粒细胞减少伴严重脓毒症或感染性休克的生存期是否存在。设计：回顾性11年研究（1998-2008）。环境：教学医院重症监护室。病人：428名患有癌症、中性粒细胞减少症和严重败血症或感染性休克的重症监护病人。主要终点是住院死亡率。结果：主要基础疾病为急性白血病（35.7%）、淋巴瘤（31.7%）和实体瘤（16.5%）。237例（55.5%）患者有微生物学记录的感染，141例（32.9%）有临床记录的感染，50例（11.9%）有不明原因的发热。428例患者中有175例（41%）诊断出急性非感染性疾病，包括50例不明原因发热患者中有26例（52%），141例临床记录感染患者中有66例（47%），237例微生物学记录感染患者中有83例（35%）。107例（25%）患者在重症监护病房入院时没有脓毒性病灶的临床证据，常规进行了早期留置导管拔管。391例（91.3%）患者采用早期β -内酰胺+氨基糖苷治疗。住院死亡率为49.8%。医院死亡率从1998-2003年的58.7%（184人中的108人）下降到2004-2008年的43%（244人中的105人，p = 0.006）。多变量分析确定了住院死亡率的9个独立预测因素，其中6个与较高的死亡率相关（年龄较大；血管加压药物的需求；神经、呼吸或肝功能障碍；急性非感染性疾病），3个与较低的死亡率相关（2003年以后入住重症监护病房，包括氨基糖苷类药物的联合抗生素治疗，以及早期留置导管移除）。结论：嗜中性粒细胞减少合并严重脓毒症或脓毒性休克的患者，生存率随着时间的推移而提高。氨基糖苷类药物的使用和早期导管拔除可能提高脓毒症患者的生存率。急性非传染性疾病与死亡率增加有关，强调需要进行彻底和反复的临床评估。（危重医疗2012；40:43-49）
Objective: To determine whether the survival gains achieved in critically ill cancer patients in recent years exist in the subset with neutropenia and severe sepsis or septic shock.Design: Retrospective 11-yr study (1998-2008).Setting: Medical intensive care unit in a teaching hospital.Patients: Four hundred twenty-eight intensive care unit patients with cancer, neutropenia, and severe sepsis or septic shock. The primary outcome was hospital mortality.Results: The main underlying diseases were acute leukemia (35.7%), lymphoma (31.7%), and solid tumors (16.5%). Two hundred thirty-seven (55.5%) patients had microbiologically documented infections, 141 (32.9%) clinically documented infections, and 50 (11.9%) fever of unknown origin. Acute noninfectious conditions were diagnosed in 175 of 428 (41%) patients, including 26 of 50 (52%) patients with fever of unknown origin, 66 of 141 (47%) patients with clinically documented infections, and 83 of 237 (35%) patients with microbiologically documented infections. Early indwelling catheter removal was performed routinely in the 107 (25%) patients without clinical evidence of a septic focus at intensive care unit admission. Early beta-lactam plus aminoglycoside therapy was used in 391 (91.3%) patients. Hospital mortality was 49.8%. Hospital mortality decreased from 58.7% (108 of 184) in 1998-2003 to 43% in 2004-2008 (105 of 244, p = .006). Multivariate analysis identified nine independent predictors of hospital mortality, of which six were associated with higher mortality (older age; need for vasopressors; neurologic, respiratory, or hepatic dysfunction; and acute noninfectious condition) and three with lower mortality (intensive care unit admission after 2003, combination antibiotic therapy including an aminoglycoside, and early indwelling catheter removal).Conclusion: In neutropenic patients with severe sepsis or septic shock, survival improved over time. Aminoglycoside use and early catheter removal in patients with undocumented sepsis may improve survival. Acute noninfectious conditions are associated with increased mortality, underlining the need for thorough and repeated clinical assessments. (Crit Care Med 2012; 40:43-49)