Elsevier

Journal of Critical Care

Volume 23, Issue 4, December 2008, Pages 475-483
Journal of Critical Care

A Focus on Sepsis
Sepsis and organ system failure are major determinants of post–intensive care unit mortality

https://doi.org/10.1016/j.jcrc.2007.09.006Get rights and content

Abstract

Purpose

The aim of the study was to investigate predictors of post–intensive care unit (ICU) in-hospital mortality with special emphasis on the impact of sepsis and organ system failure.

Methods

This study is a subanalysis of the database from the observational Sepsis Occurrence in Acutely Ill Patients study conducted in 198 ICUs in 24 European countries between May 1 and May 15, 2002. Potential predictors of post-ICU mortality were considered at 3 levels: admission status, procedures and therapy during the ICU stay, and status at ICU discharge.

Results

Of the 3147 patients included in the Sepsis Occurrence in Acutely Ill Patients study, 1729 (54.9%) were discharged to the general floor (study group) and 125 of these died (overall post-ICU hospital mortality rate, 4%); 26 (20.8%) died already the first day on the floor. Nonsurvivors were older, had higher incidence of hematologic cancer and cirrhosis, and greater Simplified Acute Physiology Score II and Sequential Organ Failure Assessment score on ICU admission; they were also more likely to have been admitted for medical reasons than survivors. In a multivariate forward stepwise logistic regression analysis, age, hematologic cancer, cirrhosis, simplified acute physiology score II on admission, medical admission, sepsis at any time during ICU stay, and organ dysfunction at ICU discharge were all independently associated with a greater risk of post-ICU death.

Conclusions

This large international study identified not only age, medical admission, and preexisting comorbidities on ICU admission but also sepsis and organ system failure as important independent risk factors for in-hospital post-ICU death.

Introduction

Mortality after discharge from the intensive care unit (ICU) remains a major concern in critically ill patients and has been reported to range from 6% to 31% [1], [2], [3], [4], [5], [6], [7], [8], [9]. Many prognostic factors for post-ICU mortality have been identified, including preadmission events [9], [10], [11], [12], severity of illness and comorbidities on admission to the ICU [7], [8], [9], and residual organ dysfunction/failure at ICU discharge [7], [8], [9]. A task force of the American College of Critical Care Medicine [13] has provided guidelines for ICU admission, discharge, and triage. However, this publication, provides relatively broad and nonspecific discharge criteria provided because of a lack of sufficient relevant data. Identifying the determinants of post-ICU death may, consequently, influence decision-making at ICU discharge, and hence may reduce mortality after ICU discharge by reducing inappropriate early discharge [14].

Factors related to therapy and evolution of the underlying disease process during the ICU stay may play an important role in determining post-ICU mortality. Sepsis syndromes are one such factor, not only because of their common occurrence in the ICU setting [15], [16], [17] but also because they are a major determinant of organ dysfunction/failure and of worse outcomes in critically ill patients [15], [17]. The aim of our study was, therefore, to investigate the predictors of post-ICU in-hospital mortality with special emphasis on the impact of sepsis syndromes and organ system failure.

Section snippets

Methods

This study is a subanalysis of the database from a prospective, multicenter, observational study, the Sepsis Occurrence in Acutely Ill Patients (SOAP) study, which was designed to evaluate the epidemiology of sepsis among ICU patients in European countries. Recruitment, data collection, and management are detailed elsewhere [17]; briefly, all patients older than 15 years admitted to the 198 participating centers (see the Appendix 1 for a list of participating countries and centers) between May

Characteristics of the study group

Of the 3147 patients enrolled in the SOAP study, 1729 (54.9%) were discharged to the general floor, 359 (1.4%) to intermediate-care units, 240 (7.6%) to other acute care facilities, 130 (4.1%) to another hospital, and 105 (3.3%) were discharged home or admitted to a long-term facility. The characteristics of the whole population and those discharged to the general floor (study group, n = 1729) are presented in Table 1. Of the 1729 patients discharged to the general floor, 125 (4%) patients

Discussion

In this large cohort, 4% of patients discharged from the ICU died on the general floor. Post-ICU mortality rates varied from 3% to 8% in the contributing countries. In addition to the severity of illness and comorbidities on ICU admission, the presence of sepsis at any time during the ICU stay and organ dysfunction at ICU discharge, as assessed by the SOFA score, were all independently associated with an increased risk of post-ICU death on the hospital floor.

The quoted incidence of post-ICU

Conclusion

This large international study identified age, medical admission, and preexisting comorbidities on ICU admission, sepsis, and organ system failure as important independent risk factors for in-hospital post-ICU death. These data may help in risk stratification and identification of potentially inappropriate early discharges from the ICU.

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    Endorsed by the European Society for Intensive Care Medicine (Brussels, Belgium), and supported by an unlimited grant from Abbott (Chicago, IL), Baxter (Deerfield, IL), Eli Lilly (Indianapolis IN), GlaxoSmithKline (Brentford, Essex, UK), and NovoNordisk.

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