Abdominal sepsis patients have a high incidence of chronic critical illness with dismal long-term outcomes

https://doi.org/10.1016/j.amjsurg.2020.07.016Get rights and content

Highlights

  • Over 1/3rd of progressed to chronic critical illness (CCI, ≥14 days in ICU with persistent organ dysfunction).

  • CCI patients had prolonged elevation of markers of proinflammation, immunosuppression, and metabolic derangement.

  • CCI patients had 1-year mortality (42%) double that of 30-day mortality (19%), with dismal 1-year performance status.

Abstract

Background

As hospital sepsis mortality has decreased, more surgical ICU survivors are progressing into chronic critical illness (CCI). This study documents the incidence of CCI and long-term outcomes of patients with abdominal sepsis. We hypothesized that patients developing CCI would have biomarker evidence of immune and metabolic derangement, with a high incidence of poor 1-year outcomes.

Methods

Review of abdominal sepsis patients entered in a prospective longitudinal study of surgical ICU sepsis.

Results

Of the 144 study patients, only 6% died early, 37% developed CCI (defined as ICU days ≥14 with organ dysfunction) and 57% were classified rapid recovery (RAP). Compared to RAP, CCI patients a) were older (66 vs 58), males who were sicker at baseline (Charlson Comorbidity Index 4 vs 2), b) had persistently elevated biomarkers of dysregulated immunity/metabolism (IL-6, IL-8, sPDL-1, GLP1), c) experienced more secondary infections (4.9 vs 2.3) and organ failure (Denver MOF frequency 40 vs 1%), d) were much more likely to have poor dispositions (85 vs 22%) with severe persistent disabilities by Zubrod Score and e) had a notably higher 1-year mortality of 42% (all p < 0.05).

Conclusion

Over 1/3rd surgical ICU patients treated for abdominal sepsis progress into CCI and experience dismal long-term outcomes.

Introduction

Despite extensive research, sepsis remains a lethal, debilitating, and expensive condition.1 Fortunately, hospital mortality has decreased substantially over the past decade as a result of rapid implementation of evidenced based interventions.2, 3, 4 Unfortunately, this success has created a growing epidemic of “sepsis survivors” who are now progressing into a lingering state of chronic critical illness (CCI).5,6 Emerging literature is documenting the dismal long-term outcomes of CCI after sepsis, but most of these reports focus on medical intensive care unit (ICU) patients being treated for pneumonia or urinary tract infections.7 Abdominal infections are the most common cause of sepsis in the surgical ICU (SICU) and their care largely falls within the domain of surgeons.8 While short-term outcomes have been well described, long-term outcomes remain poorly defined. Abdominal infections are also unique because they are associated with invasive intervention (either for source control, or being caused by a complication from surgery), which can further contribute to poor long-term outcomes.9 The purpose of this study was to analyze data from an ongoing prospective longitudinal cohort study of SICU sepsis to specifically evaluate the current epidemiology of patients treated for abdominal sepsis to determine their rate of progression into CCI, and to compare their outcomes to those who with rapid recovery (RAP). By characterizing abdominal sepsis patients who develop CCI, we hoped to gain insight into who is most likely to develop a complicated clinical course, providing both prognostic information for patients, and guidance towards future interventional research in this common surgical population. We hypothesized that patients developing CCI would have biomarker evidence of immune and metabolic derangement, with a high incidence of poor 1-year outcomes.

Section snippets

Study design

This is a subset analysis of patients treated for abdominal sepsis from an ongoing prospective cohort study of SICU patients treated for sepsis at a quaternary academic level one trauma center (University of Florida [UF] Health, Gainesville, FL). A detailed description of the study design and standard operating procedures (SOPs) utilized has been published.10 In brief, this study is approved by the UF institutional review board and registered with clinicaltrials.gov (NCT02276417). Critically

Overall cohort characteristics

Over the 40-month study period, 328 patients were enrolled into the ongoing SICU sepsis study database of which 144 (44%) patients had abdominal sepsis and were included in this analysis. Overall, roughly half of these patients were males with a median age of 63 years of which 44% were elderly (≥65 years). They had a moderate comorbidity burden by Charlson Comorbidity Index (Median 3, IQR 1–5) and significant physiologic derangement by APACHE II (median 17, IQR 12–23). There was also a high

Discussion

In this observational cohort study we have characterized the epidemiology of abdominal sepsis patients, and found that CCI is a common trajectory. Although only 6% of patients succumbed to death within 14 days, over one-third progressed to CCI. We found that abdominal sepsis patients who develop CCI are older, more comorbid, and sicker at presentation (with worse physiologic derangement and higher likelihood of septic shock) than patients that rapidly recover. We also characterized their

Author contributions

MC, SB, JS, RH, DD, AM, LM, PE, SA and FM contributed to the conception and design of the project, as well as drafting of the manuscript, revision of its content, and approved the manuscript in its final form. GG contributed to the conception and design of the project as well as data analysis and approved the manuscript in its final form.

Financial support

This work was supported by the National Institute of General Medical Sciences [NIGMS, P50 GM-111152, 2014–2020], the funded investigators included SB, GG, BB, AM, LM, PE, FM)]. It was also supported by a NIGMS postgraduate training grant in burns, trauma, and perioperative injury [T32 GM-008721, 2011–2023], the funded research fellow include MC, JS, RH, DD. The authors declare no competing financial interests.

Declaration of competing interest

All authors declare no conflicts of interest.

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