Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis

Abstract

Background: Septic shock is the most severe form of sepsis, in which profound underlying abnormalities in circulatory and cellular/metabolic parameters lead to substantially increased mortality. A clear understanding and up-to-date assessment of the burden and epidemiology of septic shock are needed to help guide resource allocation and thus ultimately improve patient care. The aim of this systematic review and meta-analysis was therefore to provide a recent evaluation of the frequency of septic shock in intensive care units (ICUs) and associated ICU and hospital mortality.

Methods: We searched MEDLINE, Embase, and the Cochrane Library from 1 January 2005 to 20 February 2018 for observational studies that reported on the frequency and mortality of septic shock. Four reviewers independently selected studies and extracted data. Disagreements were resolved via consensus. Random effects meta-analyses were performed to estimate pooled frequency of septic shock diagnosed at admission and during the ICU stay and to estimate septic shock mortality in the ICU, hospital, and at 28 or 30 days.

Results: The literature search identified 6291 records of which 71 articles met the inclusion criteria. The frequency of septic shock was estimated at 10.4% (95% CI 5.9 to 16.1%) in studies reporting values for patients diagnosed at ICU admission and at 8.3% (95% CI 6.1 to 10.7%) in studies reporting values for patients diagnosed at any time during the ICU stay. ICU mortality was 37.3% (95% CI 31.5 to 43.5%), hospital mortality 39.0% (95% CI 34.4 to 43.9%), and 28-/30-day mortality 36.7% (95% CI 32.8 to 40.8%). Significant between-study heterogeneity was observed.

Conclusions: Our literature review reaffirms the continued common occurrence of septic shock and estimates a high mortality of around 38%. The high level of heterogeneity observed in this review may be driven by variability in defining and applying the diagnostic criteria, as well as differences in treatment and care across settings and countries.

Keywords: Heterogeneity; Intensive care; Outcome; Sepsis; Sepsis definition.

Fig. 1

Frequency of septic shock in a cohort of patients admitted to the intensive care unit and diagnosed on admission. (a) All definitions except Sepsis-3. (b) Sepsis-3 only. The forest plots contain exact 95% confidence intervals, and specific studies are weighted using the inverse-variance method. The pooled summaries are obtained using the Freeman–Tukey double arcsine transformation and the DerSimonian–Laird method estimates between-study variance

Fig. 2

Frequency of septic shock within a cohort of patients admitted to the intensive care unit and diagnosed at some time during stay. (a) All definitions except Sepsis-3. (b) Sepsis-3 only. The forest plots contain exact 95% confidence intervals, and specific studies are weighted using the inverse-variance method. The pooled summaries are obtained using the Freeman–Tukey double arcsine transformation and the DerSimonian–Laird method estimates between-study variance

Fig. 3

Random effects meta-analysis of studies reporting intensive care unit mortality of septic shock patients. (a) All definitions except Sepsis-3. (b) Sepsis-3 only. The forest plots contain exact 95% confidence intervals, and specific studies are weighted using the inverse-variance method. The pooled summaries are obtained using the logit transformation and the DerSimonian–Laird method estimates between-study variance

Fig. 4

Random effects meta-analysis of studies reporting hospital mortality of septic shock patients. (a) All definitions except Sepsis-3. (b) Sepsis-3 only. The forest plots contain exact 95% confidence intervals, and specific studies are weighted using the inverse-variance method. The pooled summaries are obtained using the logit transformation and the DerSimonian–Laird method estimates between-study variance

Fig. 5

Random effects meta-analysis of studies reporting 28-/30-day mortality in septic shock patients. The forest plot contains exact 95% confidence intervals, and specific studies are weighted using the inverse-variance method. The pooled summary is obtained using the logit transformation and the DerSimonian–Laird method estimates between-study variance