Introduction
Materials and methods
The design of the Sepsi d'Oc study
Recommendations | |
---|---|
# 1 | Initial bacteriological samples drawn from sites that are suspected as the source of infection blood cultures in the first three hours |
# 2 | Initiating an empirical antibiotics therapy in the first three hours |
# 3 | Measurement of arterial lactate within the first six hours |
# 4 | Volume expansion ≥20 ml/kg within the first six hours |
# 5 | A targeted MAP > 65 mmHg within the first six hours |
# 6 | Assessments of CVP and ScvO2 within the first six hours |
# 7 | Glucose control ≤8.3 mmol/l within the first 24 hours |
# 8 | Low doses of corticosteroids when norepinephrine requirement at fewer than six hours |
# 9 | Using low tidal volume (≤8ml/kg of ideal body weight) |
# 10 | Adequate use of rhAPC within the first 24 hours |
Patients
Measurements
The present study (Figure 1)
Inclusion criteria
Exclusion criteria
Measured parameters
Statistical analysis
Results
Patient population during the study period
Hemodynamic management
Gender (Male/Female) | 257/131 | (66/34) |
---|---|---|
Age (years) (median [interquartile]) | 66 | [54 to 77] |
SAPS II at admission (median [interquartile]) | 44 | [37 to 56] |
SOFA at admission (median [interquartile]) | 7 | [5 to 9] |
ODIN score at admission (median [interquartile]) | 3 | [3 to 4] |
Type of admission | ||
Medical (n, %) | 257 | 66 |
Elective surgery (n, %) | 16 | 4 |
Emergency surgery (n, %) | 115 | 30 |
Site of causative infection | ||
Pulmonary (n, %) | 191 | 49 |
Peritonitis (n, %) | 76 | 20 |
Biliary tract infection (n, %) | 13 | 3 |
Urinary tract infection (n, %) | 39 | 10 |
Blood (n, %) | 39 | 10 |
Central nervous system (n, %) | 17 | 14 |
Others (n, %) | 48 | 12 |
Organ failure (with the duration of organ failure) | ||
Cardiovascular (n, %) | 332 | 86 |
Duration (median [interquartile]) | 4 | [2-9] |
Respiratory (n, %) | 336 | 87 |
Duration (median [interquartile]) | 11 | [5-21] |
Neurologic (n, %) | 97 | 25 |
Duration (median [interquartile]) | 6 | [3-13] |
0 to 6 hours | 6 to 24 hours | Total | |
---|---|---|---|
HES | 938 ± 529 | 830 ± 731 | 1,344 ± 951 |
Crystalloids | 1,575 ± 1,355 | 1,889 ± 1,427 | 2,965 ± 2,100 |
Total | 2,098 ± 1,597 | 2,124 ± 1,596 | 3,780 ± 2,487 |
Patients with RRT and renal dysfunction
Factors associated with renal dysfunction
Renal dysfunction | Univariate analysis | Multivariate analysis | RRT | Univariate analysis | Multivariate analysis | |||
---|---|---|---|---|---|---|---|---|
No (
n
= 237)
|
Yes (
n
= 117)
|
P
|
Renal dysfunction
OR - IC 95%
|
No RRT
N
= 298
|
RRT
N
= 90
|
P
|
RRT
| |
Age (mean ± SD)(year) | 63 ± 16 | 67 ± 14 | 0.03 | 63 ± 16 | 68 ± 15 | 0.03 | ||
Female (n, %)
| 86 (36) | 29 (25) | 1 | 108 (36) | 23 (25) | |||
Male (n, %)
| 151 (64) | 88 (75) | 0.03 | 2 [1.15 to 3.49] | 190 (64) | 67 (75) | 0.04 | |
SAPS II at admission (median with interquartile)
| 42 [35-52] | 49 [40-61] | < 0.01 | 1.03 [1.01 to 1.05] per unit | 43 [35 to 53] | 50 [40 to 63] | < 0.01 | |
Type of admission
| 1 | |||||||
Medical
| 171 (72) | 67 (57) | 3.49 [1.01-12.07] | 200 (67) | 57 (63) | |||
Elective surgery
| 6 (3) | 7 (6) | 1.94 [1.13-3.35] | 13 (4) | 3 (3) | |||
Emergency surgery
| 60 (25) | 43 (37) | 0.01 | 85 (29) | 30 (33) | 0.68 | ||
Fluid type (n, %) | ||||||||
None | 5 (2) | 2 (1) | 0.24 | 7 (2) | 2 (2) | 0.89 | ||
Crystalloids | 46 (19) | 14 (12) | 49 (17) | 14 (16) | ||||
Colloids | 19 (8) | 14 (12) | 28 (9) | 11 (12) | ||||
both | 166 (70) | 87 (74) | 214 (72) | 63 (70) | ||||
Use of colloids (n, %) | 185 (78) | 101 (86) | 0.07 | 241 (81) | 74 (82) | 0.82 | ||
Transfusion (n, %) | ||||||||
YES | 47(20) | 32 (28) | 0.07 | 70 (23) | 25 (26) | 0.49 | ||
NO | 190 (80) | 82 (72) | 228 (77) | 65 (72) | ||||
Vasopressors (n, %)
| ||||||||
YES
| 175 (74) | 106 (91) | < 0.01 | 225 (76) | 82 (91) | < 0.01 | 1 | |
NO
| 62 (26) | 11 (9) | 73 (25) | 8 (9) | 2.61 [1.18 to 5.77] | |||
Inotropic drug (n, %) | ||||||||
YES | 39 (16) | 30 (26) | 0.04 | 49 (16) | 22 (24) | 0.09 | ||
NO | 198 (84) | 87 (74) | 249 (84) | 68 (76) | ||||
Decrease in SOFA between H
0
and H
24
(n, %)
| ||||||||
YES
| 88 (37) | 27 (23) | 1 | 191 (64) | 66 (73) | |||
NO
| 149 (63) | 90 (77) | < 0.01 | 2.49 [1.40-4.41] | 107 (36) | 24 (27) | 0.11 | |
Baseline mean arterial pressure (mean ± SD) (mm Hg) | 69 ± 22 | 69 ± 20 | 0.52 | 69 ± 22 | 69 ± 21 | 0.57 | ||
Baseline central venous pressure (mean ± SD) (mm Hg)(MD = 264) | 12 ± 5 | 12 ± 5 | 0.78 | 12 ± 5 | 12 ± 5 | 0.99 | ||
Baseline arterial lactate (mean ± SD) (mMol/l)(MD = 162) | 3.4 ± 2.7 | 3.6 ± 2.8 | 0.68 | 3.4 ± 2.7 | 3.6 ± 3.0 | 0.99 | ||
History of renal dysfunction (n, %) | ||||||||
YES | 11 (5) | 3 (3) | 0.40 | 12 (4) | 3 (3) | 1.00 | ||
NO | 226 (95) | 114 (97) | 86 (96) | 87 (97) | ||||
Baseline creatinine (mean ± SD) (mMol/l)
| 122 ± 71 | 148 ± 84 | < 0.01 | 119 ± 69 | 159 ± 87 | < 0.01 | 1.006 [1.003-1.009] per unit | |
Baseline renal SOFA (n, %) | < 0.01 | < 0.01 | ||||||
0 to 1 | 174 (73) | 69 (59) | 218 (73) | 51 (57) | ||||
2-3 to 4 | 63 (27) | 48 (41) | 79 (27) | 39 (43) | ||||
Period of study
| ||||||||
Observational
| 130 (55) | 52 (44) | 0.06 | 1 | 158 (53) | 44 (49) | 0.49 | |
Interventional
| 107 (45) | 65 (56) | 1.90 [1.14-3.18] | 140 (47) | 46 (51) |
Factors associated with RRT
Discussion
Conclusions
Key messages
-
During the first 24 hours of severe sepsis or septic shock, 379 (98%) of 388 patients received fluid administration consisting exclusively of HES 130/0.4 (n = 39 (10%)) or crystalloids (n = 63 (17%)), or both HES 130/0.4 and crystalloids (n = 276 (73%)). The mean total amount of fluid given during the first 24 hours was 3,780 ± 2,487 ml. The overall mortality rate was 32%.
-
RRT was required in 90 (23%) of 388 patients. The need for vasopressors and the baseline value of plasma creatinine were independently associated with the need for RRT. The mortality rates were 52% in patients requiring RRT and 26% in those not requiring RRT (P < 0.01).
-
A renal dysfunction was diagnosed in 117 of 364 patients (32%) (34 patients were excluded because of missing information concerning the initial course of plasma creatinine). After multivariate analysis, male gender, an increase in SAPS II scores, surgical patients, no decrease in SOFA scores during the first 24 hours and the interventional period of the Sepsi d'Oc study were independently associated with renal dysfunction. The mortality rate was higher in patients with renal dysfunction than in those without renal dysfunction (48% versus 24%, P < 0.01).
-
The use of HES was not associated with RRT or renal dysfunction.