Lal Amos, Rayes Hamza, O'Horo John C, Singh Tarun D, Gajic Ognjen, Kashyap Rahul
Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
Multidisciplinary Epidemiology and Translational Research in Intensive Care-METRIC, Mayo Clinic, Rochester, MN, USA.
Ann Transl Med. 2023 Mar 15;11(5):192. doi: 10.21037/atm-22-5147. Epub 2023 Feb 24.
The proposed definition of septic shock in the Sepsis-3 consensus statement has been previously validated in critically ill patients. However, the subset of critically ill patients with sepsis and positive blood cultures needs further evaluation. To compare the combined (old and new septic shock) versus old definition of septic shock in sepsis patients that have positive blood cultures and are critically ill.
A retrospective cohort study of adult patients (age ≥18 years), who had evidence of positive blood cultures, requiring intensive care unit (ICU) admission at a large tertiary care academic center from January 2009 through October 2015. Eligible subjects who opted out of research participation, those requiring intensive care admission after elective surgery, and those who were deemed to have a low probability of infection were excluded. Basic demographics data, clinical and laboratory parameters, and outcomes of interest were pulled from the validated institutional database/repository and contrasted between the patients who qualified the new and old definitions criteria (combined) of septic shock versus the group meeting the old septic shock criteria only.
We included a total of 477 patients in the final analysis who qualified for old and new septic shock definitions. For the entire cohort, median age was 65.6 (IQR, 55-75) years, with male predominance (N=258, 54%). When compared to patients in the group who only met the old definition (N=206), the patients who met the combined (new or both new and old, N=271) definition had a higher APACHE III scores, 92 (IQR, 76-112) 76 (IQR, 61-95), P<0.001; a higher SOFA day-1 score of 10 (IQR, 8-13) 7 (IQR, 4-10), P<0.001, but did not differ significantly in age 65.5 years (IQR, 55-74) 66 years (IQR, 55-76) years, P=0.47. The patients who met the combined (new or both new and old) definition had higher chances of having conservative resuscitation preferences (DNI/DNR); 77 (28.4) 22 (10.7), P<0.001. The same group also had worse outcomes in terms of hospital mortality (34.3% 18%, P<0.001) and standardized mortality ratio (0.76 0.52, P<0.04).
In patients with sepsis with positive blood cultures, the group of patients meeting the combined definition (new or both new and old) have higher severity of illness, higher mortality, and a worse standardized mortality ratio as compared to patients meeting the old definition of septic shock.
脓毒症3共识声明中提出的脓毒性休克定义先前已在危重症患者中得到验证。然而，脓毒症且血培养阳性的危重症患者亚组需要进一步评估。目的是比较脓毒症且血培养阳性的危重症患者中合并（新旧脓毒性休克）与旧的脓毒性休克定义。
对2009年1月至2015年10月在一家大型三级医疗学术中心因血培养阳性而需要入住重症监护病房（ICU）的成年患者（年龄≥18岁）进行回顾性队列研究。排除选择不参与研究的合格受试者、择期手术后需要重症监护的患者以及被认为感染可能性低的患者。从经过验证的机构数据库/储存库中提取基本人口统计学数据、临床和实验室参数以及感兴趣的结局，并对符合新、旧脓毒性休克定义标准（合并）的患者与仅符合旧脓毒性休克标准的组进行对比。
最终分析共纳入477例符合新旧脓毒性休克定义的患者。对于整个队列，中位年龄为65.6（四分位间距，55 - 75）岁，男性占优势（N = 258，54%）。与仅符合旧定义的组（N = 206）患者相比，符合合并定义（新定义或新旧定义均符合，N = 271）的患者APACHE III评分更高，分别为92（四分位间距，76 - 112）对76（四分位间距，61 - 95），P < 0.001；第1天SOFA评分更高，分别为10（四分位间距，8 - 13）对7（四分位间距，4 - 10），P < 0.001，但年龄无显著差异，分别为65.5岁（四分位间距，55 - 74）对66岁（四分位间距，55 - 76）岁，P = 0.47。符合合并定义（新定义或新旧定义均符合）的患者有更高的保守复苏偏好（不进行心肺复苏/不进行气管插管）可能性；分别为77（28.4%）对22（10.7%），P < 0.001。同一组在医院死亡率（34.3%对（18%），P < 0.001）和标准化死亡率（0.76对0.52，P < 0.04）方面结局也更差。
在血培养阳性的脓毒症患者中，与符合旧脓毒性休克定义的患者相比，符合合并定义（新定义或新旧定义均符合）的患者疾病严重程度更高、死亡率更高且标准化死亡率更差。
