Incidence and impact of sepsis on long-term outcomes after subarachnoid hemorrhage: a prospective observational study

Abstract

Background Aneurysmal subarachnoid hemorrhage (SAH) is an acute cerebrovascular disease associated with high mortality and long-term functional impairment among survivors. Systemic inflammatory responses after acute injury and nosocomial infections are frequent complications, making the management of these patients challenging. Here, we hypothesized that sepsis might be associated with early and long-term mortality and functional outcomes. Our objective was to define the incidence of sepsis, diagnosed prospectively with the Sepsis-3 criteria, and to determine its impact on mortality and functional outcomes of patients with SAH. Methods We prospectively included all adult patients with aneurysmal SAH admitted to the intensive care unit (ICU) of a reference center between April 2016 and May 2018. Daily clinical and laboratory follow-up data were analyzed during the first 14 days, with data collected on sepsis according to the Sepsis-3 criteria. The main outcome was the functional outcome using the Modified Rankin Scale (mRS), which was assessed at hospital discharge and 3, 6 and 12 months post-discharge. Results In total, 149 patients were enrolled. The incidence of sepsis was 28%. Multivariable logistic regression analysis revealed that death or functional dependence (defined as an mRS score of 4 to 6) at hospital discharge was independently associated with sepsis (OR 3.4, 95% CI 1.16–9.96, p = 0.026) even after controlling for World Federation of Neurological Surgeons (WFNS) Scale (OR 4.66, 95% CI 1.69–12.88, p = 0.003), hydrocephalus (OR 4.55, 95% CI 1.61–12.85, p = 0.004) and DCI (OR 3.86, 95% CI 1.39–10.74, p = 0.01). Long-term follow-up mortality rates were significantly different in the septic and nonseptic groups (log-rank test p < 0.0001). The mortality rate of septic patients was 52.5%, and that of nonseptic patients was 16%. Conclusion Sepsis plays a significant role in the outcomes of patients with SAH, affecting both mortality and long-term functional outcomes. Combining high-level neurocritical care management of neurological complications and the optimal diagnosis and management of sepsis may effectively reduce secondary brain injury and improve patients’ outcomes after SAH.

Impact of Ventilator-associated Pneumonia on Cerebrospinal Fluid Inflammation During Immunosuppression After Subarachnoid Hemorrhage: A Pilot Study

“…In the clinical setting, brain injury-associated infections are associated with poor outcomes. 1,2,5,15 For example, a high proportion of CSF neutrophils has been associated with the occurrence of vasospasm after SAH. 16,17 However, it remains controversial Blood inflammatory markers were measured on days 1 to 3, 4 to 5, and 6 to 7 after SAH onset in patients without ventilator-associated pneumonia (white boxes, n=10) and with ventilator-associated pneumonia (gray boxes, n=6).…”

Sepsis-Exacerbated Brain Dysfunction After Intracerebral Hemorrhage

“…The majority of infectious patients will rapidly deteriorate and finally develop sepsis, due to systemic metabolic disorders and stress caused by excessive release of inflammatory factors and immunosuppression after ICH (Berger et al, 2014;Cheng et al, 2018). Clinically, sepsis complicated by the ICH is common but tricky in the neurosurgical intensive care unit and kills as many as a half (Goncalves et al, 2019). Our retrospective cohort study has shown that approximately 28% of patients with ICH would accompany sepsis, and sepsis is the leading cause of poor outcomes.…”

Comparative Analyses of the Impact of Different Criteria for Sepsis Diagnosis on Outcome in Patients with Spontaneous Subarachnoid Hemorrhage

“…Sepsis-1 presence of ≥2 SIRS criteria within an infection period 1 [15] sepsis according to Sepsis-1 + norepinephrine ≥ 0.1 µg/kg/min Sepsis-3_orig acute change in SOFA_orig ≥ 2 within an infection period 1 [8] sepsis according to Sepsis-3_orig + norepinephrine ≥ 0. 1) within an infection period 1 sepsis according to alternative sepsis criteria + dysfunction of cardiovascular system according to criteria (Table 1) + lactate > 2 mmol/L Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA); 1 To ensure comparability for evaluation of sepsis criteria, a time frame of 4 days around infection onset was implemented (including 2 days before the onset of infection, the day of infection onset itself, and 1 day after) as validated for robustness by Verboom et al [30]). Sepsis was considered present if the respective criteria were fulfilled within this 4-day window around infection onset.…”

“…More than 30% of patients with a spontaneous subarachnoid hemorrhage (SAH) develop infections during their hospitalization [1][2][3], and sepsis was identified as an independent risk factor for the impaired functional outcome [1,[4][5][6]. Nevertheless, data on infectious complications and sepsis in patients with an SAH remain scarce, resulting in the need for further investigations [1,7].…”