Defining persistent critical illness based on growth trajectories in patients with sepsis

Zhongheng Zhang,Kwok M Ho,Yunsong Yu,Hongqiu Gu,Yucai Hong

doi:10.1186/s13054-020-2768-z

Abstract

BackgroundPersistent critical illness is common in critically ill patients and is associated with vast medical resource use and poor clinical outcomes. This study aimed to define when patients with sepsis would be stabilized and transitioned to persistent critical illness, and whether such transition time varies between latent classes of patients.MethodsThis was a retrospective cohort study involving sepsis patients in the eICU Collaborative Research Database. Persistent critical illness was defined at the time when acute physiological characteristics were no longer more predictive of in-hospital mortality (i.e., vital status at hospital discharge) than antecedent characteristics. Latent growth mixture modeling was used to identify distinct trajectory classes by using Sequential Organ Failure Assessment score measured during intensive care unit stay as the outcome, and persistent critical illness transition time was explored in each latent class.ResultsThe mortality was 16.7% (3828/22,868) in the study cohort. Acute physiological model was no longer more predictive of in-hospital mortality than antecedent characteristics at 15 days after intensive care unit admission in the overall population. Only a minority of the study subjects (n = 643, 2.8%) developed persistent critical illness, but they accounted for 19% (15,834/83,125) and 10% (19,975/198,833) of the total intensive care unit and hospital bed-days, respectively. Five latent classes were identified. Classes 1 and 2 showed increasing Sequential Organ Failure Assessment score over time and transition to persistent critical illness occurred at 16 and 27 days, respectively. The remaining classes showed a steady decline in Sequential Organ Failure Assessment scores and the transition to persistent critical illness occurred between 6 and 8 days. Elevated urea-to-creatinine ratio was a good biochemical signature of persistent critical illness.ConclusionsWhile persistent critical illness occurred in a minority of patients with sepsis, it consumed vast medical resources. The transition time differs substantially across latent classes, indicating that the allocation of medical resources should be tailored to different classes of patients.

Highlights

Due to a variety of reasons such as hospital-acquired complications, endocrine dysregulation, unresolved inflammation, and protein catabolism, a substantial number of critically ill patients require prolonged intensive care unit (ICU) stay [1]
The trajectories of the 5 classes are shown in Fig. 1: class 1 (22.8%) was characterized by persistent low severity of illness, with a slightly increasing trend; class 2 (3.55%) was characterized by increasing severity of illness; class 3 (51.7%) was characterized by moderate initial Sequential Organ Failure Assessment (SOFA) followed by decreasing severity of illness during the course of ICU stay; class 4 (11.2%) was characterized by high initial SOFA and slightly decreasing course; and class 5 (10.8%) was characterized by a persistent high severity of illness with a high mortality rate of 41.2%
The goodness-of-fit statistics for the 5-class model were maximum loglikelihood = − 189,328.67, Akaike information criterion (AIC) = 378,697.33, and Bayesian information criteria (BIC) = 378,858.08

Summary

Introduction

Due to a variety of reasons such as hospital-acquired complications, endocrine dysregulation, unresolved inflammation, and protein catabolism, a substantial number of critically ill patients require prolonged intensive care unit (ICU) stay [1]. The term persistent critical illness (PCI) was coined referring to the situation when a patient’s initial. Zhang et al Critical Care (2020) 24:57 the most common causes of prolonged ICU stay. Sepsis is a risk factor for ICU-acquired weakness and delirium [7,8,9]. Many of these hospital-acquired complications may contribute to a septic patient’s prolonged ICU stay [10,11,12], increasing the chance of developing PCI. This study aimed to define when patients with sepsis would be stabilized and transitioned to persistent critical illness, and whether such transition time varies between latent classes of patients

Objectives

Methods

Results

Discussion

Conclusion