Current Epidemiology of Surgical Sepsis: Discordance Between Inpatient Mortality and 1-year Outcomes

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.

Figure 1.. Long-term performance status after sepsis.

(A) Long-term performance status over 12-month longitudinal follow-up. Baseline represents self-reported pre-sepsis performance status. *3, 6, and 12-month assessments compared to baseline, p<0.0001. (B) Long-term performance status comparing older (≥65 years), middle-age (46–64 years) and young (≤45 years) adults. *older vs middle-age and older vs young, both p<0.001. (C) Long-term performance status of chronic critical illness (CCI) as compared to rapid recovery (RAP) inpatient clinical trajectories. *CCI vs RAP, p<0.005.

Figure 2.. Post-sepsis 12-month survival.

(A) Overall cohort 12-month survival. (B) 12-month survival by older (≥65 years), middle-age (46–64 years) and young (≤45 years) age groups. *older vs middle-age and older vs young, log rank test both p<0.005. (C) 12-month survival comparing CCI to RAP clinical trajectories. *Cox proportional hazard controlling for age and Charlson comorbidity score, p<0.0001.