Top

Published in:

Open Access 01-12-2016 | Research

Septic shock with no diagnosis at 24 hours: a pragmatic multicenter prospective cohort study

Authors: Damien Contou, Damien Roux, Sébastien Jochmans, Rémi Coudroy, Emmanuel Guérot, David Grimaldi, Sylvie Ricome, Eric Maury, Gaëtan Plantefève, Julien Mayaux, Armand Mekontso Dessap, Christian Brun-Buisson, Nicolas de Prost

Published in: Critical Care | Issue 1/2016

Abstract

Background

The lack of a patent source of infection after 24 hours of management of shock considered septic is a common and disturbing scenario. We aimed to determine the prevalence and the causes of shock with no diagnosis 24 hours after its onset, and to compare the outcomes of patients with early-confirmed septic shock to those of others.

Methods

We conducted a pragmatic, prospective, multicenter observational cohort study in ten intensive care units (ICU) in France. We included all consecutive patients admitted to the ICU with suspected septic shock defined by clinical suspicion of infection leading to antibiotic prescription plus acute circulatory failure requiring vasopressor support.

Results

A total of 508 patients were admitted with suspected septic shock. Among them, 374 (74 %) had early-confirmed septic shock, while the 134 others (26 %) had no source of infection identified nor microbiological documentation retrieved 24 hours after shock onset. Among these, 37/134 (28 %) had late-confirmed septic shock diagnosed after 24 hours, 59/134 (44 %) had a condition mimicking septic (septic shock mimicker, mainly related to adverse drug reactions, acute mesenteric ischemia and malignancies) and 38/134 (28 %) had shock of unknown origin by the end of the ICU stay. There were no differences between patients with early-confirmed septic shock and the remainder in ICU mortality and the median duration of ICU stay, of tracheal intubation and of vasopressor support. The multivariable Cox model showed that the risk of day-60 mortality did not differ between patients with or without early-confirmed septic shock. A sensitivity analysis was performed in the subgroup (n = 369/508) of patients meeting the Sepsis-3 definition criteria and displayed consistent results.

Conclusions

One quarter of the patients admitted in the ICU with suspected septic shock had no infection identified 24 hours after its onset and almost half of them were eventually diagnosed with a septic shock mimicker. Outcome did not differ between patients with early-confirmed septic shock and other patients.

Available only for authorised users

Phua J, Ngerng W, See K, Tay C, Kiong T, Lim H, Chew M, Yip H, Tan A, Khalizah H, et al. Characteristics and outcomes of culture-negative versus culture-positive severe sepsis. Crit Care. 2013;17(5):R202.CrossRefPubMedPubMedCentral

Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. 2006;34(2):344–53.CrossRefPubMed

Brun-Buisson C, Doyon F, Carlet J, Dellamonica P, Gouin F, Lepoutre A, Mercier JC, Offenstadt G, Regnier B. Incidence, risk factors, and outcome of severe sepsis and septic shock in adults. A multicenter prospective study in intensive care units. French ICU Group for Severe Sepsis. JAMA. 1995;274(12):968–74.CrossRefPubMed

Heffner AC, Horton JM, Marchick MR, Jones AE. Etiology of illness in patients with severe sepsis admitted to the hospital from the emergency department. Clin Infect Dis. 2010;50(6):814–20.CrossRefPubMedPubMedCentral

Klein Klouwenberg PM, Cremer OL, van Vught LA, Ong DS, Frencken JF, Schultz MJ, Bonten MJ, van der Poll T. Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study. Crit Care. 2015;19:319.CrossRefPubMedPubMedCentral

Reyes WJ, Brimioulle S, Vincent JL. Septic shock without documented infection: an uncommon entity with a high mortality. Intensive Care Med. 1999;25(11):1267–70.CrossRefPubMed

Cohen J, Brun-Buisson C, Torres A, Jorgensen J. Diagnosis of infection in sepsis: an evidence-based review. Crit Care Med. 2004;32(11 Suppl):S466–494.CrossRefPubMed

Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580–637.CrossRefPubMed

Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;101(6):1644–55.CrossRefPubMed

10.

Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801–10.CrossRefPubMedPubMedCentral

11.

Bersten AD, Edibam C, Hunt T, Moran J. Incidence and mortality of acute lung injury and the acute respiratory distress syndrome in three Australian States. Am J Respir Crit Care Med. 2002;165(4):443–8.CrossRefPubMed

12.

Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–68.CrossRefPubMed

13.

Combes A, Mokhtari M, Couvelard A, Trouillet JL, Baudot J, Henin D, Gibert C, Chastre J. Clinical and autopsy diagnoses in the intensive care unit: a prospective study. Arch Intern Med. 2004;164(4):389–92.CrossRefPubMed

14.

Tejerina E, Esteban A, Fernandez-Segoviano P, Maria Rodriguez-Barbero J, Gordo F, Frutos-Vivar F, Aramburu J, Algaba A. Gonzalo Salcedo Garcia O, Lorente JA. Clinical diagnoses and autopsy findings: discrepancies in critically ill patients*. Crit Care Med. 2012;40(3):842–6.CrossRefPubMed

15.

Frohlich S, Ryan O, Murphy N, McCauley N, Crotty T, Ryan D. Are autopsy findings still relevant to the management of critically ill patients in the modern era? Crit Care Med. 2013;42(2):336–43.CrossRef

16.

Chariot P, Witt K, Pautot V, Porcher R, Thomas G, Zafrani ES, Lemaire F. Declining autopsy rate in a French hospital: physician's attitudes to the autopsy and use of autopsy material in research publications. Arch Pathol Lab Med. 2000;124(5):739–45.PubMed

17.

Roberts IS, Benamore RE, Benbow EW, Lee SH, Harris JN, Jackson A, Mallett S, Patankar T, Peebles C, Roobottom C, et al. Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study. Lancet. 2012;379(9811):136–42.CrossRefPubMedPubMedCentral

18.

Wichmann D, Obbelode F, Vogel H, Hoepker WW, Nierhaus A, Braune S, Sauter G, Pueschel K, Kluge S. Virtual autopsy as an alternative to traditional medical autopsy in the intensive care unit: a prospective cohort study. Ann Intern Med. 2012;156(2):123–30.CrossRefPubMed

19.

Leone M, Bechis C, Baumstarck K, Ouattara A, Collange O, Augustin P, Annane D, Arbelot C, Asehnoune K, Baldesi O, et al. Outcome of acute mesenteric ischemia in the intensive care unit: a retrospective, multicenter study of 780 cases. Intensive Care Med. 2015;41(4):667–76.CrossRefPubMed

20.

Roberts RJ, Barletta JF, Fong JJ, Schumaker G, Kuper PJ, Papadopoulos S, Yogaratnam D, Kendall E, Xamplas R, Gerlach AT, et al. Incidence of propofol-related infusion syndrome in critically ill adults: a prospective, multicenter study. Crit Care. 2009;13(5):R169.CrossRefPubMedPubMedCentral

21.

de Prost N, Razazi K, Brun-Buisson C. Unrevealing culture-negative severe sepsis. Crit Care. 2013;17(5):1001.CrossRefPubMedPubMedCentral

22.

Bloos F, Sachse S, Kortgen A, Pletz MW, Lehmann M, Straube E, Riedemann NC, Reinhart K, Bauer M. Evaluation of a polymerase chain reaction assay for pathogen detection in septic patients under routine condition: an observational study. PLoS One. 2012;7(9):e46003.CrossRefPubMedPubMedCentral

23.

Vincent JL, Brealey D, Libert N, Abidi NE, O'Dwyer M, Zacharowski K, Mikaszewska-Sokolewicz M, Schrenzel J, Simon F, Wilks M, et al. Rapid diagnosis of infection in the critically ill, a multicenter study of molecular detection in bloodstream infections, pneumonia, and sterile site infections. Crit Care Med. 2015;43(11):2283–91.CrossRefPubMedPubMedCentral

Title: Septic shock with no diagnosis at 24 hours: a pragmatic multicenter prospective cohort study
Authors: Damien Contou
Damien Roux
Sébastien Jochmans
Rémi Coudroy
Emmanuel Guérot
David Grimaldi
Sylvie Ricome
Eric Maury
Gaëtan Plantefève
Julien Mayaux
Armand Mekontso Dessap
Christian Brun-Buisson
Nicolas de Prost
Publication date: 01-12-2016
Publisher: BioMed Central
Published in: Critical Care / Issue 1/2016
Electronic ISSN: 1364-8535
DOI: https://doi.org/10.1186/s13054-016-1537-5

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Septic shock with no diagnosis at 24 hours: a pragmatic multicenter prospective cohort study

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2016

Should we continue to use prediction tools to identify patients at risk of Candida spp. infection? If yes, why?

Future of sepsis therapies

Hybrid blood purification strategy in pediatric septic shock

Guidewire exchange vs new site placement for temporary dialysis catheter insertion in ICU patients: is there a greater risk of colonization or dysfunction?

Surviving critical illness: what is next? An expert consensus statement on physical rehabilitation after hospital discharge

The impairment of small nerve fibers in severe sepsis and septic shock