research article

High Prevalence and High Risk of Death for Sepsis Associated Brain Dysfunction in ICU: A Cohort Study from Quick Diagnostic Tests

Dao-Ming.Tong 1 ,Guang-Sheng. Wang 1 , Yuan-Wei.Wang 1 , Ye-Ting.  Zhou 2 , Shao-Dan.Wang 3 , Ying. Wang 1

1 Department of Neurology, Affiliated Shuyang Hospital, Xuzhou Medical University, Jiangsu, China

2 Department of Surgery, Affiliated Shuyang Hospital of Xuzhou Medical University, Jiangsu, China

3 Department of Intensive Care Medicine, Affiliated Shuyang Hospital, Xuzhou Medical University, Jiansu, China

*Corresponding author: Dao-Ming.Tong, Department of Neurology, Affiliated Shuyang Hospital, Xuzhou Medical University, Jiangsu, China

Received Date: 09 December, 2022

Accepted Date: 17 December, 2022

Published Date: 21 December, 2022

Citation: Tong DM, Wang GS, Wang YW, Zhou YT, Wang SD, et al. (2022) High Prevalence and High Risk of Death for Sepsis Associated Brain Dysfunction in ICU: A Cohort Study from Quick Diagnostic Tests. Int J Nurs Health Care Res 5: 1377. DOI: https://doi.org/10.29011/2688-9501.101377

Abstract

Purpose Whether sepsis associated brain dysfunction (SABD) would present an high prevalence and high risk of death in ICU, while is still unknown. Methods: We retrospectively enrolled patients with acute critically ill with sepsis from a single ICU in a medical University of China (January 1, 2018 to November 30, 2019). All patients were selected from onset to ICU stay>24 hours. We used a continuous head and thorax/abdominal cavity CT scans to screen infection before on admission. We also measured the dynamic profile of laboratory findings. The risk factors of death in SABD was estimated by using a logistic- regression analysis. Results: A total of 214 critically ill patients with sepsis from onset to initial 24 hours in ICU was diagnosed by Sequential [sepsisrelated] Organ Failure Assessment (SOFA) criteria. Of them, 202 SABD (94.4%, 202/214) was identified according to SOFA criteria for the brain. 135 was male (66.8 %) with mean age 66.7 ± 16.1 years. The most common SABD was delirium (50.0 %) ,followed by a stupor or coma (35.1%). Among the 202 sepsis patients with SABD, the most common infection was pneumonia/ lungs infection (86.6%, 175/202). The fatality of SABD was 60.4% at initial 60 days. By multifactors regression analysis, severe inflammatory storm (OR, 7.2; 95% CI, 2.58- 24.94), higher SOFA scores (OR, 1.8; 95% CI, 1.5-3.6), and elevated CRP level (OR, 1.0; 95% CI, 1.26-1.96) were the independent risk factors for death in SABD. Conclusions: SABD in ICU is an high prevalent life-threatening acute organ dysfunction. The bad prognosis in SABD was related to the severe inflammatory storm, higher SOFA score, and elevated CPR level.

Keywords:Sepsis; Acute brain dysfunction; Infection; Inflammatory storm; Prevalence; Outcome.

Introduction

Sepsis as an most frequent complication in critically ill adults has been become the leading cause of morbidity and mortality worldwide [1-3]. Moreover, in 2016, the Third International Consensus (sepsis-3) has defined sepsis as a life-threatening organ dysfunction due to a dysregulated host response to infection [4]. To the best of our knowledge, the brain dysfunction if is closely related to sepsis is defined as equivalent to a Sequential Organ Failure Assessment (SOFA) score ≥1 (on a scale from 0 to 4) [5]. The value of This SOFA criteria for diagnosis sepsis associated brain dysfunction (SABD) have reported by documents [3-6], especially it has been accepted by sepsis-3 [4]. However, whether a SABD in ICU would present an high prevalence and high risk of death, which is still understanding incomplete. Our hypothesis was that the critical ill adults in ICU would be having an high rate of prevalence from community-acquired infection and high risk of death in SABD. The aim of this study was to clear whether these SABD present an high prevalence and high risk of death in ICU, so to cognize its important of prevention/control SABD.

Methods

Procedures and population

We conducted a retrospective cohort study from adult patients with sepsis who were admitted to The Affiliated Shuyang Hospital of Xuzhou Medical University, a 21-bed tertiary care hospital, from Jan 1, 2018, to Nov 30, 2019 with a length of stay of more than 24 hours. We examined the electronic medical records of patients who were verified as having a brain-chest-abdomen CT scan before on admission. We excluded possible critically ill patients who did not have CT data before on the ICU, or no medical records due to either death or transport out of the ICU within the first 24 hours. The study was approved by the ethical committee on clinical research of the Affiliated Shuyang Hospital of Xuzhou Medical University, and written informed consent was obtained from parents or legal guardian.

Patients identification, inclusion criteria, related definitions, and mainly measurement for SABD

SABD is defined as equivalent to a SOFA score ≥ 1 for the brain organ (on a scale from 0 to 4) [5]. We used this SOFA criteria for the brain to assess acute brain dysfunction/brain failure during the initial 24 hrs in ICU .

In this study, diagnosis of sepsis is based on one or more life-threatening organ dysfunction (a total SOFA scores ≥ 2 points) caused by infection. The identification of infection event is meant a suspected or confirmed infection (e.g., a cold, SIRS ≥ 2, confirmed pneumonia or other infection). In the present study, the time of onset infection is limited to before organ failure. If there is only an isolated brain failure, the time of onset infection had to be before (or simultaneously) brain dysfunction rather than behind it. Thus, these critically ill patients who were performed a continuous head and chest /abdominal CT scans before on admission were enrolled in this study. It is more likely to detect the ultra-early infection of chest (pneumonia) and abdominal (gallbladder/ cholangitis, peritonitis, pancreatitis).

Systemic inflammatory response syndrome (SIRS) has been recognized as a clinical manifestations host response to infection. A systemic inflammatory response mainly involves to a massive inflammatory cytokine release [7]. More recently, it’s called a cytokine storm, which is a life-threatening systemic inflammatory storm [8]. Moreover, this inflammatory syndrome also involves other inflammatory mediators in the blood (e.g; D-dimer, C-reactive protein, and procalcitonin). The clinical manifestations of SIRS include follow 4 points: (1) temperature> 38°C or < 36° C; (2) heart rate >90 beats per minute; (3) tachypnea> 20 respirations per minute or or PCo2 less than 32mmHg ; (4) white blood cell count > 12.0×109/L or < 4.0×10 9/L, or > 10% band forms. The identified criteria for SIRS must be at least ≥ 2 points/scores (≥3 points/scores= severe). We also measured the dynamic profile of laboratory findings, SIRS sores, SOFA scores, and so forth, which can effect on outcomes.

Our primary outcome was the prevalence of SABD. Our secondary outcomes were the in–hospital mortality at 60 days in ICU on the SABD nonsurvivors or survivors. The outcome events were reviewed by two of the investigators (the first and second author).In order to assessment the outcomes of patients in-hospital 60 days, survival state was confirmed by the medical records. If the patient died after discharge, the information was followed-up to 60 days.

Data collected

All clinical data were gathered from the electronic medical records written by residents or attending physicians of the emergency and ICU. In addition to collect the cranial and thorax/ abdominal cavity CT scans findings, the collected clinical profile for this study in ICU included the patient demographics, time from critically ill event to infection, initial SIRS level, initial SOFA score, initial GCS score (or GCS motor score if the patients were in intubation), vital sign data, experimental/ laboratorial data, mechanical ventilation, traditional treatment, length of stay (LOS) in the ICU, and outcomes.

Statistical methods

The results in each group were expressed as mean ± standard deviation (SD) or medians (IQR), and n (%) for qualitative values. Fisher’s exact test and the Mann-Whitney U test were used to examine the relationship between baseline patient variables. Continuous variables were compared using Student’s t test. Multivariate-adjusted odds ratios (OR) and 95% confidence intervals (CIs) were estimated using a logistic-regression model if they were significant in the univariate analysis. Differences between patients was considered significant if the p-value was <0.05. Statistical calculations were performed using a proprietary,computerized statistics package (SPSS 17.0.).

Results

A total of 214 critically ill adult patients with sepsis were admitted to ICU, which was met the inclusion criteria for sepsis-3. Finally, 202 patients with SABD (94.4%,202/214) were diagnosed and included in this study. Of them, there was 149 (73.8%) community-acquired SABD and 53 (26.2%) hospital-acquired SABD. Based on SOFA for brain criteria, the distribution of SABD within initial 72 hours in the ICU was showed in the Table 1. Of these patients, the most common initial presenting SABD were delirium [101 (50..0%)], followed by acute stupor/coma [71 (35.1%)]. The Study population included 132 males and 70 females, with the average age of 67 years. The clinical characteristics of the 202 SABD are shown in Table 2. The median time from onset to ICU admission was 3.2 hours (range, 0.5-240 h).

SOFA for the brain

 

SABD

N,%

N = 202

SOFA score 1 (GCS=13-14)= delirium

101

50

SOFA score 2 (GCS=10-12)= drowsiness

20

10

SOFA score 3 (GCS=6-9)= stupor/ coma

71

35

SOFA score 4 (GCS<6)= deep coma

10

5

All of SABD

202

100

Table 1: SOFA score for the brain to diagnosis SABD within first 72 h in ICU (n = 202); Abbreviation-ICU: Intensive Care Unit; GCS: Glasgow Coma Scale; SOFA: Sequential [sepsis-related] Organ Function Assessment; SABD: Sepsis Associated Brain Dysfunction.

 

Total

(n = 202)

Non-survivors

(n = 115)

Survivors

(n = 87)

p Value

 
 

Age (years, mean ± SD)

66.7 ± 16.1

68.1 ± 16.1

65.0 ± 16.1

 

0.181

Male gender (n,%)

135(66.8)

77(67.0)

58(66.7)

 

1

Initial GCS score,(mean±SD)

10.5 ± 3.3

10.3 ± 3.1

10.7 ± 3.5

 

0.522

Comorbidities

         

Hypertension (n,%)

98(48.5)

54(47.0)

44(50.6)

 

0.67

Cardiac-cerebral vesculardisease (n,%)

72(35.6)

39(33.9)

33(37.9)

 

0.557

Diabetes (n,%)

35(17.3)

22(19.1)

13(14.9)

 

0.46

Clonical lung disease (n,%)

30(14.9)

11(9.6)

19(21.8)

 

0.017

Cancer (n,%)

19(9.4)

10 (8.7)

9(10.3)

 

0.809

Initial presenting symptoms

         

Fever, (n,%)

91(45.0)

59(41.3)

32(36.8)

 

0.046

Alterd mental status/deliriun, (n,%)

88(43.6)

57(50.0)

31(35.6)

 

0.062

Acute stopor/coma, (n,%)

73(36.1)

49(42.6)

24(27.6)

 

0.038

Cough/dyspnea, (n,%)

64(31.7)

44(38.3)

20(23.0)

 

0.023

Chest/abdominal pain, (n,%)

12(6.0)

6(5.0)

6(6.9)

 

0.766

Dizziness/headache,(n,%)

11(5.4)

5(4.3)

6(7.0)

 

0.536

Other, (n,%)

5(2.5)

3(2.6)

2(2.3)

 

1

Acute pneumonia/lung infection, n (%)

174(86.1)

98(85.0)

76(87.4)

 

0.236

Abdomen infection, n. (%)

18 (10.0)

13(10.9)

5(5.3)

 

0.138

Other infection. n (%)

12 (5.9)

8(7.0)

4(4.6)

 

0.497

Community-acquired sepsis, n (%)

158(78.2)

88(76.5)

70(80.5)

 

0.006

Median(IQR) time from onset to ICU(hours)

3.2(0.5-240)

2.7(0.5-144)

5.5(0.5-240)

 

0.012

Median (IQR) temperature (°C)n (%)

37.5(35.3-40.0)

37.8(36-40.0)

36.9(35.3-39.7)

 

0.075

Median(IQR)arterial pressure(mmHg)

93(40-160)

93(40-160)

98.7(90-130)

 

0.266

Median(IQR)Heart rate(beats/min)

102(58-107)

102(70-107)

102(58-148)

 

0.354

Median(IQR)Respiratory rate(breaths/mim)

27(0-45)

27(5-35)

27(0-45)

 

0.818

MODS, n (%)

188(93.!)

115(100.0)

73(83.9)

 

0

Intubation and IMV, n (%)

198(98.0)

115(100.0)

83(95.4)

 

0

Antibiotic therapy during initial 6 hours, n (%)

202(100.0)

115(100.0)

87(100.0)

NA

 

Antibiotic therapy within initial 1 hours, n (%)

94(46.5)

43(37.4)

51(58.6)

 

0.003

LOS (days,IQR)

9.8(1-127)

7.7(1-90)

12(2-127)

 

0.305

Mortality at 60 days, n (%)

122(60.4)

NA

NA

NA

 

Table 2: Clinical characteristics in patients with SABD (n=202); Abbreviations-ICU: Intensive Care Unit; GCS: Glasgow Coma Scale; SOFA: Sequential [sepsis-related] Organ Function Assessment; IMV: Invasive Mechanical Ventilation; LOS: Length of Stay; IQR: Interquartile Range,MODS: Multiple Organ Dysfunction Syndrome.

Among the 202 sepsis patients with SABD, the most common infection was pneumonia/lungs infection (84.6%, 171/202) and early onset of pneumonia is more likely to relate to rapid brain edema/SABD (Figures 1 and 2). The secondary causes was abdominal infection (10.0%) , followed by other infection(5.4%). The outcome of using antibiotics treatment within initial 1.0 hours in ICU was better in the survivors with SABD than in those nonsurvivors with SABD ( 58.6% VS, 37.4%; p<0.005). The subsequent confirmed that patients with positive blood culture were 15.3% of SABD and patients with abnormal CSF analysis were 14.4% of SABD. In all SABD patients, the risk of death was 35.4% at the initial 72 hours and 60.4 % (122/202) at the initial 60 days.

 

Figure 1: The features of brain / chest/abdominal computed tomographic (CT) images; Figure 1 A-C is from a 57 year-old female patient with fever 2 days and drowsiness 1 day was admitted. On day 1, brain CT showed the focus of infection and diffuse edema (A), chest CT showed bilateral pneumonia(B), and abdominal CT showed the focus of infection (C), On days 3, fever up to 39.0°C, On days 3 blood pressure drop to 81/54mmHg, and deep coma, On days 4, she died and was discharged.