Abstract
BackgroundSepsis-3 definitions were published recently and validated only in high-income countries. The aim of this study was to assess the new criteria’s accuracy in stratifying mortality as compared to its predecessor (Sepsis-2) in a Brazilian public intensive care unit (ICU) and to investigate whether the addition of lactate values would improve stratification.MethodsRetrospective cohort study conducted between 2010 and 2015 in a public university’s 19-bed ICU. Data from patients admitted to the ICU with sepsis were retrieved from a prospectively collected database. ICU mortality was compared across categories of both Sepsis-2 definitions (sepsis, severe sepsis and septic shock) and Sepsis-3 definitions (infection, sepsis and septic shock). Area under the receiving operator characteristic curves were constructed, and the net reclassification index and integrated discrimination index for the addition of lactate as a categorical variable to each stratum of definition were evaluated.ResultsThe medical records of 957 patients were retrieved from a prospectively collected database. Mean age was 52 ± 19 years, median SAPS 3 was 65 [50,79], respiratory tract infection was the most common cause (42%, 402 patients), and 311 (32%) patients died in ICU. The ICU mortality rate was progressively higher across categories of sepsis as defined by the Sepsis-3 consensus: infection with no organ dysfunction—7/103 (7%); sepsis—106/419 (25%); and septic shock—198/435 (46%) (P < 0.001). For Sepsis-2 definitions, ICU mortality was different only across the categories of severe sepsis [43/252-(17%)] and septic shock [250/572-(44%)] (P < 0.001); sepsis had a mortality of 18/135-(13%) (P = 0.430 vs. severe sepsis). When combined with lactate, the definitions’ accuracy in stratifying ICU mortality only improved with lactate levels above 4 mmol/L. This improvement occurred in the severe sepsis and septic shock groups (Sepsis-2) and the no-dysfunction and septic shock groups (Sepsis-3). Multivariate analysis demonstrated similar findings.ConclusionsIn a Brazilian ICU, the new Sepsis-3 definitions were accurate in stratifying mortality and were superior to the previous definitions. We also observed that the new definitions’ accuracy improved progressively with severity. Serum lactate improved accuracy for values higher than 4 mmol/L in the no-dysfunction and septic shock groups.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0204-y) contains supplementary material, which is available to authorized users.
Highlights
Sepsis-3 definitions were published recently and validated only in high-income countries
The new clinical criteria of sepsis proposed by the third international consensus (Sepsis-3) could predict mortality in infected patients admitted to a strained intensive care unit (ICU) in a middle-income country
The prognostic value of the new definition of sepsis was progressive along all three categories, which denotes a spectrum of gravity of infectious process and could help in risk stratification for future studies in this area of research
Summary
Sepsis-3 definitions were published recently and validated only in high-income countries. The panel recognized several factors that could be used to identify patients with severe sepsis and associated with increased mortality, leading to important efforts for the early recognition and treatment of severe sepsis and septic shock This consensus developed the PIRO concept (predisposition, infection, response, organ failure); this idea was not largely translated to clinical practice [4]. The methodology used to capture SIRS criteria may lead to substantial variability in defining sepsis cases [7, 8] These and other concerns have led to the development and publication of new sepsis definitions (Sepsis-3), which were derived through a data-driven mortality risk stratification [9,10,11]. Some criticisms include the new definitions’ lack of validation in scenarios outside of high-income countries, and their non-utilization of lactate as a marker of organ dysfunction [12,13,14,15,16]
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