The impact of delayed source control and antimicrobial therapy in 196 patients with cholecystitis-associated septic shock: a cohort analysis

Abstract

Background: Cholecystitis-associated septic shock carries a significant mortality. Our aim was to determine whether timing of source control affects survival in cholecystitis patients with septic shock. Methods:We conducted a nested cohort study of all patients with cholecystitisassociated septic shock from an international, multicentre database (1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015). Multivariable logistic regression was performed to determine associations between clinical factors and in-hospital mortality. The results were used to inform a classification and regression tree (CART) analysis that modelled the association between disease severity (APACHE II), time to source control and survival.Results: Among 196 patients with cholecystitis-associated septic shock, overall mortality was 37%. Compared with nonsurvivors (n = 72), survivors (n = 124) had lower mean admission APACHE II scores (21 v. 27, p < 0.001) and lower median admission serum lactate (2.4 v. 6.8 µmol/L, p < 0.001). Survivors were more likely to receive appropriate antimicrobial therapy earlier (median 2.8 v. 6.1 h from shock, p = 0.012). Survivors were also more likely to undergo successful source control earlier (median 9.8 v. 24.7 h from shock, p < 0.001). Adjusting for covariates, APACHE II (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.06-1.21 per increment) and delayed source control > 16 h (OR 4.45, 95% CI 1.88-10.70) were independently associated with increased mortality (all p < 0.001). The CART analysis showed that patients with APACHE II scores of 15-26 benefitted most from source control within 16 h (p < 0.0001). Conclusion:In patients with cholecystitis-associated septic shock, admission APACHE II score and delay in source control (cholecystectomy or percutaneous chole cystostomy drainage) significantly affected hospital outcomes.Contexte : Le choc septique associé à une cholécystite s'accompagne d'une mortalité significative. Notre but était de déterminer si le moment du contrôle de la source affecte la survie chez les patients atteints de cholécystite qui se trouvent en choc septique.Méthodes : Nous avons procédé à une étude de cohorte nichée regroupant tous les patients ayant présenté un choc septique associé à une cholécystite à partir d'une base de données multicentrique internationale (1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015). La régression logistique multivariée a été utilisée pour déterminer les liens entre les facteurs cliniques et la mortalité perhospitalière. Les résultats ont été utilisés pour éclairer une analyse par arbre de classification (CART) qui modélisait le lien entre la gravité de la maladie (APACHE II), le temps nécessaire au contrôle de la source et la survie.Résultats : Parmi 196 patients souffrant d'un choc septique associé à une cholécystite, la mortalité globale a été de 37 %. Comparativement aux patients décédés (n = 72), les survivants (n = ...

Leukocyte kinetics during the early stage acts as a prognostic marker in patients with septic shock in intensive care unit

“…In this study, we found significantly difference in age, APACHE II and SOFA scores, the proportion of cancer and homological cancer between survivors and non-survivors. These results were similar to previous studies [27–29] . In Angus's report, chronic diseases, for instance, the acquired immunodeficiency syndrome, chronic obstructive pulmonary disease and many cancers, are also risk factors for the infections that most commonly precipitate severe sepsis and septic shock [25] .…”

“…These results were similar to previous studies. [27][28][29] In Angus's report, chronic diseases, for instance, the acquired immunodeficiency syndrome, chronic obstructive pulmonary disease and many cancers, are also risk factors for the infections that most commonly precipitate severe sepsis and septic shock. [25] Unfortunately, even if we detect these risk factors of mortality, no management strategies can be changed to improve the outcome in patients with septic shock due to these risk factors can not be treated.…”

Major Publications in the Critical Care Pharmacotherapy Literature: 2021

“…The results of Jackson et al ( 43 ) suggest that septic patients will experience a more substantial mortality benefit when controlled to receive balanced crystalloids in both the emergency department and ICU compared with later when they are admitted to the ICU. This is consistent with other aspects of sepsis care, wherein a faster time to appropriate antibiotic administration and source control are also associated with improved mortality ( 43 , 44 ). A previous analysis showed no correlation between time to completion of a 30 mL/kg IV fluid bolus and mortality, but the type of fluid was not tracked ( 45 ).…”

Basic point‐of‐care ultrasound framework based on the airway, breathing, and circulation approach for the initial management of shock and dyspnea

“…However, if left undetected, acute cholecystitis will likely lead to serious complications, including perforation, septic shock, multiorgan failure, and death. 49 When performing POCUS for the evaluation of acute cholecystitis, the presence of gallstones, gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy sign provide diagnostic information. 50 Summers et al 51 reported in a prospective observational study of 164 patients that the test characteristics of POCUS for the detection of acute cholecystitis had a sensitivity of 87% (95% CI, 66-97%) and specificity of 82% (95% CI, 74-88%).…”

“…Acute cholecystitis is usually diagnosed when the inflammation is localized to the gallbladder. However, if left undetected, acute cholecystitis will likely lead to serious complications, including perforation, septic shock, multiorgan failure, and death . When performing POCUS for the evaluation of acute cholecystitis, the presence of gallstones, gallbladder wall thickening, pericholecystic fluid, and sonographic Murphy sign provide diagnostic information .…”