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

Abstract

Background: Persistent 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.Methods: This 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. Results: The 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 beddays, 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. Conclusions: While 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.

Improving nutritional therapy of persistent critically ill patients by organisational measures: A before and after study

“…Elevated urea-to-creatinine ratio has been shown to be a good biochemical signature of persistent critical illness [6], at least after major trauma [19]. This sign was obviously present in the majority of our patients and the ratio increased significantly over time in both periods, although 30% of the patients remained below the cutoff of 100 indicated by Haynes et al [19].…”

“…Every critically ill patient staying for more than 48 h in the intensive care unit (ICU) should be considered at risk for malnutrition and screened for this risk to establish a nutrition therapy [2]. Patients with "persistent critical illness" (PCI) [3] are characterized by prolonged need of life support [4,5] and are at particular risk of malnutrition [4,6,7]. After surviving their initial insult, these patients remain dependent on techniques exclusively available in the ICU and require up to several months before they can be discharged to a lower intensity ward.…”

Influence of the trajectory of the urine output for 24 h on the occurrence of AKI in patients with sepsis in intensive care unit

“…In latent growth mixture modeling (LGMM), the population is assumed to be heterogeneous and composed of several latent classes of subjects characterized by a number of mean profiles of trajectories [ 15 ]. In this study, we used the LGMM model to classify the 24-h urine output change trajectory of sepsis patients from the large public database Medical Information Mart for Intensive Care IV (MIMIC-IV).…”

Tertiary peritonitis: considerations for complex team-based care

“…Sepsis related organ failure impacts all organ systems with approximately 50% of all acute kidney injury in the critically ill being ascribed as a sequela of infection [48]. Both accelerated morbidity and mortality are attributed to non-resolving organ dysfunction in the setting of sepsis and septic shock [49][50][51][52][53][54]. However, the specific mechanisms by which organ failure management hinders or enables host defense are less clearly defined and outcomes may be substantially driven by patient phenotype as opposed to specific intervention [11].…”