The Epidemiology, Therapeutic Patterns, Outcome, and Challenges in Managing Septic Shock in a Sub-Saharan African Intensive Care Unit: A Cross-Sectional Study

Document Type: Original Article

Authors

1 Department of Anesthesiology and Critical Care, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon

2 Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon

3 Department of Emergency Medicine, Anesthesiology and Critical Care, Douala General Hospital, Douala, Cameroon

4 Department of Anesthesiology and Critical Care, Gynaeco-Obstetrics and Paediatric Hospital, Yaoundé, Cameroon

Abstract

Background: Septic shock (SS) is a health priority in sub-Saharan Africa. However, there is a dearth of data in this regard.
Objective: This study aimed to determine the epidemiology, therapeutic patterns, outcome, and challenges in managing SS in a tertiary intensive care unit (ICU) of sub-Saharan Africa.
Methods: The hospital files of 36 consecutive patients admitted to the ICU of the Douala General Hospital (DGH), Cameroon over the year 2018 were reviewed for SS. SS was diagnosed based on Sepsis-3 definition. Demographic and clinical characteristics, treatment details, and outcomes of patients with SS were reviewed. Data was analyzed using the chi-square or Fisher exact tests and Bonferroni correction.
Results: SS accounted for 36 (9.4%) ICU admissions. The majority of patients were males (63.9%). The most common site of infection was the lungs. The mean age, average mean arterial pressure (MAP), and mean sequential organ failure assessment (SOFA) score of patients were 52.9±25.2 years, 52±18 mm Hg, and 9.2 ±2.3, respectively. Noradrenaline was the sole vasopressor used. Therapeutic challenges included the inability to have a specific antibiogram before a mean duration of 7 days. The mortality rate was 39% and associated with age ≤1 year, MAP ≤ 65 mm Hg, Glasgow Coma Score (GCS) ≤8, and mechanical ventilation, which were not attenuated after Bonferroni correction.
Conclusion: SS is a frequent cause of ICU admission and is associated with a high mortality rate. SS mortality-related factors can be screened during SS management for more aggressive ICU management geared at preventing death.

Keywords


  1. Reinhart K, Daniels R, Kissoon N, Machado FR, Schachter RD, Finfer S. Recognizing sepsis as a global health priority--a WHO resolution. N Engl J Med. 2017;377(5):414-417. doi:10.1056/NEJMp1707170.
  2. Balcan B, Olgun Ş, Torlak F, Sağmen SB, Eryüksel E, Karakurt S. Determination of factors affecting mortality of patients with sepsis in a tertiary intensive care unit. Turk Thorac J. 2015;16(3):128-132. doi:10.5152/ttd.2015.4510.
  3. Cohen J. The immunopathogenesis of sepsis. Nature. 2002;420(6917):885-891. doi:10.1038/nature01326.
  4. Yende S, Austin S, Rhodes A, et al. Long-term quality of life among survivors of severe sepsis: analyses of two international trials. Crit Care Med. 2016;44(8):1461-1467. doi:10.1097/CCM.0000000000001658.
  5. Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term cognitive impairment and functional disability among survivors of severe sepsis. Jama. 2010;304(16):1787-1794. doi:10.1001/jama.2010.1553.
  6. Prescott HC, Osterholzer JJ, Langa KM, Angus DC, Iwashyna TJ. Late mortality after sepsis: propensity matched cohort study. BMJ. 2016;353:i2375. doi:10.1136/bmj.i2375.
  7. Thompson K, Venkatesh B, Finfer S. Sepsis and septic shock: current approaches to management. Intern Med J. 2019;49(2):160-170. doi:10.1111/imj.14199.
  8. Fleischmann C, Scherag A, Adhikari NK, et al. Assessment of global incidence and mortality of hospital-treated sepsis. Current estimates and limitations. Am J Respir Crit Care Med. 2016;193(3):259-272. doi:10.1164/rccm.201504-0781OC.
  9. Liu V, Escobar GJ, Greene JD, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA. 2014;312(1):90- 92. doi:10.1001/jama.2014.5804.
  10. Shankar-Hari M, Phillips GS, Levy ML, et al. Developing a new definition and assessing new clinical criteria for septic shock: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):775-787. doi:10.1001/jama.2016.0289.
  11. Sakr Y, Jaschinski U, Wittebole X, et al. Sepsis in intensive care unit patients: worldwide data from the intensive care over nations audit. Open Forum Infect Dis. 2018;5(12):ofy313. doi:10.1093/ofid/ofy313.
  12. Annane D, Aegerter P, Jars-Guincestre MC, Guidet B. Current epidemiology of septic shock: the CUB- Réa Network. Am J Respir Crit Care Med. 2003;168(2):165-172. doi:10.1164/rccm.2201087.
  13. Zhang W, Zheng Y, Feng X, Chen M, Kang Y. Systemic inflammatory response syndrome in Sepsis-3: a retrospective study. BMC Infect Dis. 2019;19(1):139. doi:10.1186/s12879-019-3790-0.
  14. Finfer S, Machado FR. The global epidemiology of sepsis. does it matter that we know so little? Am J Respir Crit Care Med. 2016;193(3):228-230. doi:10.1164/rccm.201510-1976ED.
  15. Mbeng LO. Informal waste recovery and recycling: alleviating poverty, environmental pollution and unemployment in Douala, Cameroon. J Sci Res Rep. 2013;2(1):474-490. doi:10.9734/JSRR/2013/4436.
  16. Rogers S. The Top 50 most expensive cities. Guardian. 2009. http://www.guardian.co.uk/news/datablog/2009/jul/07/global-economy-economics. Accessed October 9, 2019.
  17. Vincent JL, Jones G, David S, Olariu E, Cadwell KK. Frequency and mortality of septic shock in Europe and North America: a systematic review and meta-analysis. Crit Care. 2019;23(1):196. doi:10.1186/s13054-019-2478-6.
  18. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.
  19. Quenot JP, Binquet C, Kara F, et al. The epidemiology of septic shock in French intensive care units: the prospective multicenter cohort EPISS study. Crit Care. 2013;17(2):R65. doi:10.1186/cc12598.
  20. Ranieri VM, Thompson BT, Barie PS, et al. Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med. 2012;366(22):2055-2064. doi:10.1056/NEJMoa1202290.
  21. Boussekey N, Cantrel J, Dorchin Debrabant L, et al. Epidemiology, prognosis, and evolution of management of septic shock in a French intensive care unit: a five years survey. Crit Care Res Pract. 2010;2010:436427. doi:10.1155/2010/436427.
  22. Baharoon S, Telmesani A, Tamim H, et al. Community- versus nosocomial-acquired severe sepsis and septic shock in patients admitted to a tertiary intensive care in Saudi Arabia, etiology and outcome. J Infect Public Health. 2015;8(5):418-424. doi:10.1016/j.jiph.2014.12.003.
  23. Vincent JL, de Mendonca A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26(11):1793-1800. doi:10.1097/00003246-199811000-00016.
  24. Vincent JL, Sakr Y, Sprung CL, et al. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. 2006;34(2):344-353. doi:10.1097/01.ccm.0000194725.48928.3a.
  25. Sakr Y, Elia C, Mascia L, et al. Epidemiology and outcome of sepsis syndromes in Italian ICUs: a muticentre, observational cohort study in the region of Piedmont. Minerva Anestesiol. 2013;79(9):993-1002.
  26. Wynn JL, Wong HR. Pathophysiology and treatment of septic shock in neonates. Clin Perinatol. 2010;37(2):439-479. doi:10.1016/j.clp.2010.04.002.
  27. Alalawi MSM, Aljabran HAM, Alkhamri AM, et al. Glasgow Coma Scale in Anticipation of Sepsis and Septic Shock: Review Article. Egypt J Hosp Med. 2017;69(6):2663-2666. doi:10.12816/0042245.
  28. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818-829. doi:10.1097/00003246-198510000-00009.
  29. Eidelman LA, Putterman D, Putterman C, Sprung CL. The spectrum of septic encephalopathy. Definitions, etiologies, and mortalities. JAMA. 1996;275(6):470-473. doi:10.1001/ jama.1996.03530300054040.
  30. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580-637. doi:10.1097/CCM.0b013e31827e83af.
  31. Dünser MW, Takala J, Ulmer H, et al. Arterial blood pressure during early sepsis and outcome. Intensive Care Med. 2009;35(7):1225-1233. doi:10.1007/s00134-009-1427-2.
  32. Strandgaard S, Olesen J, Skinhoj E, Lassen NA. Autoregulation of brain circulation in severe arterial hypertension. Br Med J. 1973;1(5852):507-510. doi:10.1136/bmj.1.5852.507.
  33. Carlucci A, Richard JC, Wysocki M, Lepage E, Brochard L. Noninvasive versus conventional mechanical ventilation. An epidemiologic survey. Am J Respir Crit Care Med. 2001;163(4):874-880. doi:10.1164/ajrccm.163.4.2006027.
  34. Namendys-Silva SA, Hernández-Garay M, Rivero-Sigarroa E, Herrera-Gómez A. Ventilator-associated pneumonia and septic shock in emergency colorectal procedures in elderly patients. Arch Surg. 2010;145(6):602. doi:10.1001/archsurg.2010.73.
  35. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-1596. doi:10.1097/01.ccm.0000217961.75225.e9.
  36. Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38(4):1045- 1053. doi:10.1097/CCM.0b013e3181cc4824.
  37. Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. 2004;32(3):858-873. doi:10.1097/01.CCM.0000117317.18092.E4.
  38. Sartelli M, Kluger Y, Ansaloni L, et al. Raising concerns about the Sepsis-3 definitions. World J Emerg Surg. 2018;13:6. doi:10.1186/s13017-018-0165-6.
  39. Jung YT, Jeon J, Park JY, Kim MJ, Lee SH, Lee JG. Addition of lactic acid levels improves the accuracy of quick sequential organ failure assessment in predicting mortality in surgical patients with complicated intra-abdominal infections: a retrospective study. World J Emerg Surg. 2018;13:14. doi:10.1186/s13017-018-0173-6.
  40. Kashyap R, Singh TD, Rayes H, et al. Association of septic shock definitions and standardized mortality ratio in a contemporary cohort of critically ill patients. J Crit Care. 2019;50:269-274. doi:10.1016/j.jcrc.2019.01.005.
  41. Carneiro AH, Póvoa P, Gomes JA. Dear Sepsis-3, we are sorry to say that we don’t like you. Rev Bras Ter Intensiva. 2017;29(1):4-8. doi:10.5935/0103-507X.20170002.
  42. Liu ZM, Chen J, Kou Q, et al. Terlipressin versus norepinephrine as infusion in patients with septic shock: a multicentre, randomised, double-blinded trial. Intensive Care Med. 2018;44(11):1816-1825. doi:10.1007/s00134-018-5267-9.
  43. Díaz LE, Montero A, Gonzalez-Gross M, Vallejo AI, Romeo J, Marcos A. Influence of alcohol consumption on immunological status: a review. Eur J Clin Nutr. 2002;56 Suppl 3:S50-53. doi:10.1038/sj.ejcn.1601486.
  44. von Dossow V, Schilling C, Beller S, et al. Altered immune parameters in chronic alcoholic patients at the onset of infection and of septic shock. Crit Care. 2004;8(5):R312-321. doi:10.1186/cc2911.