High Mortality in Severe Sepsis and Septic Shock Patients with Do-Not-Resuscitate Orders in East Asia

Abstract

BackgroundSevere sepsis is a potentially deadly illness and always requires intensive care. Do-not-resuscitate (DNR) orders remain a debated issue in critical care and limited data exist about its impact on care of septic patients, particularly in East Asia. We sought to assess outcome of severe sepsis patients with regard to DNR status in Taiwan.MethodsA retrospective cohort study was conducted in intensive care units (ICUs) between 2008 and 2010. All severe sepsis patients were included for analysis. Primary outcome was association between DNR orders and ICU mortality. Volume of interventions was used as proxy indicator to indicate aggressiveness of care.ResultsSixty-seven (9.4%) of 712 patients had DNR orders on ICU admission, and these patients were older and had higher disease severity compared with patients without DNR orders. Notably, DNR patients experienced high ICU mortality (90%). Multivariate analysis revealed that the presence of DNR orders was independently associated with ICU mortality (odds ratio: 6.13; 95% confidence interval: 2.66–14.10). In propensity score-matched cohort, ICU mortality rate (91%) in the DNR group was statistically higher than that (62%) in the non-DNR group (p <0.001). Regarding ICU interventions, arterial and central venous catheterization were more commonly used in DNR patients than in non-DNR patients.ConclusionsFrom the Asian perspective, septic patients placed on DNR orders on ICU admission had exceptionally high mortality. In contrast to Western reports, DNR patients received more ICU interventions, reflecting more aggressive approach to dealing with this patient population. The findings in some ways reflect differences between East and West cultures and suggest that DNR status is an important confounder in ICU studies involving severely septic patients.

Reduction in the IL-6 level at 24 h after admission to the intensive care unit is a survival predictor for Vietnamese patients with sepsis and septic shock: a prospective study

“…Sepsis and septic shock are the most common causes of death in the ICU [ 23 , 24 ]. In recent years, the age of patients suffering from sepsis admitted to the ICU has been increasing [ 5 ]. The mean age of our study cohort was 58.2 ± 18.8 years, the duration of ICU stay was 6 (IQR 3–12) days, and 39.0% of patients survived.…”

“…Sepsis and septic shock are common problems in intensive care units (ICUs). The corresponding mortality for sepsis and septic shock is 24.3–60.0% even in developed countries [ 1 – 5 ]. This mortality rate has decreased 1.3% annually since 2012 due to early diagnosis and appropriate empiric antibiotic therapy [ 6 , 7 ].…”

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“…Through advances in organ support, those with severe dengue may have a greater chance to survive, but DNR orders precludes the intensive care provided by healthcare workers. In Taiwan, old age is the main factor in signing DNR orders in critically ill patients [32, 33]. A study in Taiwan revealed that patients with renal failure had the highest percentage of signed DNR orders [34].…”

Yiqi Fumai Injection for patients with Septic Shock: study protocol for a randomized controlled trial1

“…Septic shock is defined as a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality [1]. Currently, it has been estimated to account for more than 19 million new cases worldwide each year, and 6 million deaths [2].The mortality rate is more than 1/4, and about 3 million of the surviving patients have cognitive dysfunction [3,4].Clinically, approximately 50% of patients with sepsis progress to septic shock, and the mortality rate of septic shock could be as high as 50% or more [5][6][7][8].Zhou et al [9] showed that the overall hospital mortality rate of patients with severe sepsis/septic shock in the comprehensive intensive care unit in mainland China was 33.5%. A study in Taiwan, China, found that 28-day mortality rate in patients with severe sepsis/septic shock in the local surgical intensive care unit was 61% [10].Complex pathogenesis, severe clinical manifestations, and limited treatment made it as one of the leading causes of death in ICU [11][12].Even if survived after treatment, the long-term quality of life is significantly lower than that of the average person [13][14][15].…”