Merih KALAMANOĞLU, Nalan ADIGÜZEL, Gökay GÜNGÖR, Cüneyt SALTÜRK, Zuhal KARAKURT, Ece ÖZ, Gülbanu HORZUM, Özlem MOÇİN YAZICIOĞLU, Özkan DEVRAN, Adnan YILMAZ

Risk factors for multiorgan failure and mortality in severe sepsis patients who need intensive care unit follow-up

Giriş: Çoklu organ yetmezliği (ÇOY) yoğun bakım ünitelerinde önde gelen morbidite ve mortalite nedenlerinden biridir. Sepsis hastalarında ÇOY gelişimine katkı sağlayan risk faktörlerinin tespit edilmesi ve önlenebilir problemlerin çözümlenmesi mortaliteyi azaltmada önemli bir adım olabilir. Bu çalışmada yoğun bakımda yatan sepsis hastalarında ÇOY ve mortalite ile bağlantılı risk faktörlerinin araştırılması amaçlanmıştır. Hastalar ve Metod: Retrospektif veri toplamaya dayalı prognostik kohort çalışması gerçekleştirilmiştir. Ocak 2009-Mart 2010 tarihleri arasında, 22 yataklı solunumsal yoğun bakım ünitesine sepsis tanısı ile yatırılan hastalar çalışmaya dahil edilmiştir. Hastaların demografik verileri, Yoğun bakım ünitesi (YBÜ) ciddiyet skorları, mekanik ventilasyon uygulaması, sepsise neden olan ajan, yoğun bakımda kalış süreleri ve mortalite varlığı kayıt edilmiş olup risk faktörleri için lojistik regresyon analizi uygulanmıştır. Bulgular: Çalışmaya 347 sepsis hastası dahil edilmiştir. Kırk üç hastada (%12.4) ÇOY gelişmiş olup genel mortalite oranı %14.9dur (n= 52). ÇOY gelişimi için risk faktörleri dirençli patojen ve şok varlığı, total parenteral beslenme (TPB) ve yüksek APACHE II skoru olarak bulunmuştur. (sırasıyla p= 0.015 Odds oranı (OR) 3.47 güven aralığı (CI): 1.27 - 9.47, p= 0.001, OR: 30.8 CI: 11.41 - 83 - 49, p= 0.028, OR: 3.08, CI: 1.13 - 8.39, p= 0.003, OR: 1.10, CI: 1.04 - 1.18). Genel mortalite risk faktörleri ise nozokomiyal infeksiyon varlığı, üçüncü gün yüksek SOFA skoru, şok varlığı, sedasyon ve TPBdir. (sırasıyla p= 0.005, OR: 3.39, CI: 1.45 - 7.93; p = 0.001, OR: 1.51, CI: 1.27 - 1.81; p= 0.014, OR: 3.24, CI: 1.27 - 8.25; p= 0.003, OR: 3.64. CI: 1.54 - 8.58; p= 0.001, OR: 3.38, CI: 1.51 - 7.57). Sonuç: Yoğun bakımda takibi gereken sepsis hastalarında dirençli patojen varlığı, şok, TPB uygulanması ve yüksek APACHE II skoru ÇOY gelişimi açısından risk faktörleridir. Bu nedenle akılcı antibiyotik kullanımı, TPB uygulamasının azaltılması, infeksiyon kontrol programlarının uygulanması ve şokun önlenmesi çoklu organ yetmezliği ve mortaliteyi azaltacaktır.

Yoğun bakımda takip edilen sepsisli hastalarda çoklu organ yetmezliği ve mortalite için risk faktörleri

Introduction: Multiorgan failure (MOF) is a primary cause of morbidity and mortality in sepsis patients in intensive care units (ICU). Finding risk factors and solving preventable problems of MOF in patients who have sepsis can be a favourable step for decreasing mortality. We aimed to examine multiorgan failure and mortality related risk factors in intensive care unit patients who have sepsis. Materials and Methods: A retrospective data collection and prognostic cohort study was performed. Between January 2009-March 2010, patients accepted to the 22-bed pulmonary intensive care unit with the diagnosis of sepsis were enrolled. Patients demographic data, ICU severity scores, application of mechanical ventilation, causative agent of sepsis, number of ICU days and presence of mortality were recorded. Logistic regression analysis was carried out for risk factors. Results: 347 patients with sepsis were involved in the study. 43 of the patients (12.4%) developed MOF and overall mortality rate was 14.9% (n= 52). Presence of resistant pathogen, presence of shock, application of TPN and high APACHE II score were found to be risk factors for MOF [p= 0.015 Odds ratio (OR) 3.47 confidence interval (CI): 1.27 - 9.47, p= 0.001, OR: 30.8 CI: 11.41 - 83-49, p= 0.028, OR: 3.08, CI: 1.13 - 8.39, p= 0.003, OR: 1.10, CI: 1.04-1.18, respectively]. Risk factors for overall mortality were presence of nosocomial infection, high 3rd day SOFA score, presence of shock, application of TPN and sedation (p= 0.005, OR: 3.39, CI: 1.45 - 7.93; p= 0.001, OR: 1.51, CI: 1.27 - 1.81; p= 0.014, OR: 3.24, CI: 1.27 - 8.25; p= 0.003, OR: 3.64. CI: 1.54 - 8.58; p= 0.001, OR: 3.38, CI: 1.51 - 7.57, respectively). Conclusions: In sepsis patients who need ICU follow up, presence of resistant pathogen, presence of shock, application of TPN and high APACHE II scores are risk factors for developing MOF. Thus, rational use of antibiotics, reducing the use of TPN, application of infection control programmes and prevention of shock will further reduce multiorgan failure and mortality

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1. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Intensive Care Med 2003;29:530-8.
2. Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, et al; Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858-73.
3. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2000. Crit Care Med 2008;36:296-327.
4. Sakr Y, Lobo SM, Moreno RP, Gerlach H, Ranieri VM, Michalopoulos A, et al; SOAP Investigators. Patterns and early evolution of organ failure in the intensive care unit and their relation to outcome. Crit Care 2012;16:R222.
5. Vincent JL, Nelson DR, Williams MD. Is worsening multiple organ failure the cause of death in patients with severe sepsis? Crit Care Med 2011;39:1050-5.
6. Hotchkiss RS, Karl IE. The pathophysiology and management of sepsis. N Engl J Med 2003;348:138-50.
7. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985;13;818-29.
8. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996;22:707-10.
9. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992;20:864- 74.
10. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342:1301-8.
11. Briegel J, Forst H, Haller M, Schelling G, Kilger E, Kuprat G, et al. Stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, randomized, double-blind, single-center study. Crit Care Med 1999;27:723-32.
12. Annane D, Sébille V, Charpentier C, Bollaert PE, François B, Korach JM, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002;288:862-71.
13. Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, et al. CORTICUS Study Group. Hydrocortisone Therapy for Patients with Septic Shock. N Eng J Med 2008;358:111-24.
14. Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, et al; NICE-SUGAR Study Investigators. Intensive versus conventional glucose control incritically ill patients. N Engl J Med 2009;360:1283-97.
15. Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, et al. Intensive insulin therapy in the medical ICU. N Engl J Med 2006;354:449-61.
16. Majid A, Hill NS. Noninvasive ventilation for acute respiratory failure. Curr Opin Crit Care 2005;11:77-81.
17. Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, et al. Weaning from mechanical ventilation. Eur Respir J 2007;29:1033-56.
18. Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002;166:1338-44.
19. Trouillet JL, Chastre J, Vuagnat A, Joly-Guillou ML, Combaux D, Dombret MC, et al. Ventilator-associated pneumonia caused by potentially drug-resistant bacteria. Am J Respir Crit Care Med 1998;157:531-9.
20. Levy MM, Rhodes A, Phillips GS, Townsend SR, Schorr CA, Beale R, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year Study. Intensive Care Med 2014;40:1623-33.
21. van Zanten AR, Brinkman S, Arbous MS, Abu-Hanna A, Levy MM, de Keizer NF, et al; Netherlands Patient Safety Agency Sepsis Expert Group. Guideline bundles adherence and mortality in severe sepsis and septic shock. Crit Care Med 2014;42:1890-8.
22. Peake SL, Delaney A, Bailey M, Bellomo R, Cameron PA, Cooper DJ, et al; ARISE Investigators; ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014;371:1496-506.
23. Penning S, Chase JG, Preiser JC, Pretty CG, Signal M, Mélot C, et al. Does the achievement of an intermediate glycemic target reduce organ failure and mortality? A post hoc analysis of the Glucontrol trial. J Crit Care 2014;29:374-9.
24. Knox DB, Lanspa MJ, Pratt CM, Kuttler KG, Jones JP, Brown SM. Glasgow Coma Scale score dominates the association between admission Sequential Organ Failure Assessment score and 30-day mortality in a mixed intensive care unit population. J Crit Care 2014;29:780-5.
25. Houck PM, Bratzler DW, Nsa W, Ma A, Bartlett JG. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med 2004;164:637-44.
26. Metersky ML, Sweeney TA, Getzow MB, Siddiqui F, Nsa W, Bratzler DW. Antibiotic timing and diagnostic uncertainty in Medicare patients with pneumonia: is it reasonable to expect all patients to receive antibiotics within 4 hours? Chest 2006;130:16-21.
27. Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34:1589-96.
28. Vazquez-Guillamet C, Scolari M, Zilberberg MD, Shorr AF, Micek ST, Kollef M. Using the number needed to treat to assess appropriate antimicrobial therapy as a determinant of outcome in severe sepsis and septic shock. Crit Care Med 2014;42:2342-9.
29. Cahill NE, Dhaliwal R, Day AG, Jiang X, Heyland DK. Nutrition therapy in the critical care setting: what is best achievable practice? An international multicenter observational study. Crit Care Med 2010;38:395-401.
30. Steffen EK, Berg RD, Deitch EA. Comparison of translocationrates of various indigenous bacteria from the gastrointestinal tract to the mesenteric lymph node. J Infect Dis 1988;157:1032-8.
31. Vollaard EJ, Clasener HA. Colonization resistance. Antimicrob Agents Chemother 1994;38:409-14
32. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2009;33:277-316.
33. Lee KS, Sheen SS, Jung YJ, Park RW, Lee YJ, Chung WY, et al. Consideration of additional factors in Sequential Organ Failure Assessment score. J Crit Care 2014;29:185.e9-185. e12.
34. Oltean S, Tatulescu D, Bondor C, Slavcovici A, Cismaru C, Lupşe M, et al. Charlson's weighted index of comorbidities is useful in assessing the risk of death in septic patients. J Crit Care 2012;27:370-5.