Abstract
BackgroundTetanus remains common in many low- and middle-income countries, but as critical care services improve, mortality from tetanus is improving. Nevertheless, patients develop severe syndromes associated with autonomic nervous system disturbance (ANSD) and the requirement for mechanical ventilation (MV). Understanding factors associated with worse outcome in such settings is important to direct interventions. In this study, we investigate risk factors for disease severity and long-term physical outcome in adults with tetanus admitted to a Vietnamese intensive care unit.MethodsClinical and demographic variables were collected prospectively from 180 adults with tetanus. Physical function component scores (PCS), calculated from Short Form Health Survey (SF-36), were assessed in 79 patients at hospital discharge, 3 and 6 months post discharge.ResultsAge, temperature, heart rate, lower peripheral oxygen saturation (SpO2) and shorter time from first symptom to admission were associated with MV (OR 1.03 [ 95% confidence interval (CI) 1.00, 1.05], p = 0.04; OR 2.10 [95% CI 1.03, 4.60], p = 0.04; OR 1.04 [ 95% CI 1.01, 1.07], p = 0.02); OR 0.80 [95% CI 0.66, 0.94], p = 0.02 and OR 0.65 [95% CI 0.52, 0.79, p < 0.001, respectively).Heart rate, SpO2 and time from first symptom to admission were associated with ANSD (OR 1.03 [95% CI 1.01, 1.06], p < 0.01; OR 0.95 [95% CI 0.9, 1.00], p = 0.04 and OR 0.64 [95% CI 0.48, 0.80], p < 0.01, respectively).Median [interquartile range] PCS at hospital discharge, 3 and 6 months were 32.37 [24.95–41.57, 53.0 [41.6–56.3] and 54.8 [51.6–57.3], respectively. Age, female sex, admission systolic blood pressure, admission SpO2, MV, ANSD, midazolam requirement, hospital-acquired infection, pressure ulcer and duration of ICU and hospital stay were associated with reduced 0.25 quantile PCS at 6 months after hospital discharge.ConclusionsMV and ANSD may be suitable endpoints for future research. Risk factors for reduced physical function at 3 months and 6 months post discharge suggest that modifiable features during hospital management are important determinants of long-term outcome.
Highlights
Tetanus remains common in many low- and middle-income countries, but as critical care services improve, mortality from tetanus is improving
Risk factors for reduced physical function at 3 months and 6 months post discharge suggest that modifiable features during hospital management are important determinants of long-term outcome
Tetanus is a vaccine-preventable disease associated with severe muscle spasm and cardiovascular system disturbance that remains a common cause of acute critical illness in low- and middle-income countries (LMICs) [1]
Summary
Tetanus remains common in many low- and middle-income countries, but as critical care services improve, mortality from tetanus is improving. Tetanus is a vaccine-preventable disease associated with severe muscle spasm and cardiovascular system disturbance that remains a common cause of acute critical illness in low- and middle-income countries (LMICs) [1]. Historical literature contains many studies documenting risk factors for mortality in tetanus when muscle spasm were the principal causes of death [6, 7]. It is unclear whether these same risk factors are important in modern ICU settings where death due to respiratory muscle spasms can be prevented by mechanical ventilation [5, 8]. As mortality rates decrease, predicting those at risk of other outcomes such as mechanical ventilation or ANSD may be more relevant to everyday clinical practice and clinical trial outcomes [9, 10]
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