Current Epidemiology of Surgical Sepsis

Discordance Between Inpatient Mortality and 1-Year Outcomes

Scott C. Brakenridge, MD; Philip A. Efron, MD; Michael C. Cox, MD; Julie A. Stortz, MD; Russell B. Hawkins, MD; Gabriela Ghita, MS; Anna Gardner, PhD; Alicia M. Mohr, MD; Stephen D. Anton, PhD; Lyle L. Moldawer, PhD; Frederick A. Moore, MD

Disclosures

Annals of Surgery. 2019;270(3):502-510. 

In This Article

Abstract and Introduction

Abstract

Objective: We sought to compare traditional inpatient outcomes to long-term functional outcomes and mortality of surgical intensive care unit (SICU) patients with sepsis.

Summary of Background Data: As inpatient sepsis mortality declines, an increasing number of initial sepsis survivors now progress into a state of chronic critical illness (CCI) and their post-discharge outcomes are unclear.

Methods: We performed a prospective, longitudinal cohort study of SICU patients with sepsis.

Results: Among this recent cohort of 301 septic SICU patients, 30-day mortality was 9.6%. Only 13 (4%) patients died within 14 days, primarily of refractory multiple organ failure (62%). The majority (n = 189, 63%) exhibited a rapid recovery (RAP), whereas 99 (33%) developed CCI. CCI patients were older, with greater comorbidities, and more severe and persistent organ dysfunction than RAP patients (all P < 0.01). At 12 months, overall cohort performance status was persistently worse than presepsis baseline (WHO/Zubrod score 1.4 ± 0.08 vs 2.2 ± 0.23, P> 0.0001) and mortality was 20.9%. Of note at 12 months, the CCI cohort had persistent severely impaired performance status and a much higher mortality (41.4%) than those with RAP (4.8%) after controlling for age and comorbidity burden (Cox hazard ratio 1.27; 95% confidence interval, 1.14–1.41, P < 0.0001). Among CCI patients, independent risk factors for death by 12 months included severity of comorbidities and persistent organ dysfunction (sequential organ failure assessment ≥6) at day 14 after sepsis onset.

Conclusions: There is discordance between low inpatient mortality and poor long-term outcomes after surgical sepsis, especially among older adults, increasing comorbidity burden and patients that develop CCI. This represents important information when discussing expected outcomes of surgical patients who experience a complicated clinical course owing to sepsis.

Introduction

Sepsis remains one of the largest health care burdens in the United States, with an estimated annual incidence of 1.7 million sepsis cases and annual hospital care costs exceeding US $20 billion dollars.[1] Recent epidemiology studies estimate that sepsis is present in 30% to 50% of hospitalizations that culminate in death.[1,2] Most of these reports come from medical intensive care units (ICUs), where septic patients often present with severe chronic comorbidities and thus most of their deaths are unpreventable.[1] In contrast, surgeons are less likely to operate on these severely debilitated patients and consequently inpatient mortality after surgical sepsis has substantially decreased during the past 15 years as a result of early sepsis screening and reliable implementation of evidence based ICU care.[3,4] Many patients who previously succumbed to early refractory shock and later multiple organ failure (MOF) now survive their index hospitalization.[5] However, a disturbing number of these "sepsis survivors" develop a clinical trajectory of chronic critical illness (CCI), with a prolonged ICU course, high resource utilization, and persistent but manageable organ dysfunctio n.[6–8] These patients have an underlying pathophysiologic syndrome of persistent inflammation, immunosuppression, and catabolism with evidence of elevated circulating inflammatory biomarkers, innate immune suppression and lean body mass protein catabolism out to 28 days after sepsis onset.[7,9] Almost all are discharged to high resource post-discharge care facilities that are known to be associated with poor long-term outcomes.[6,7] The purpose of this report was to describe the current epidemiology of surgical sepsis in a prospective cohort, specifically to compare traditional in-hospital outcomes to previously poorly documented long-term outcomes.

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