Comparative analysis of survival between elderly and non-elderly severe sepsis and septic shock resuscitated patients

Palomba, Henrique; Corrêa, Thiago Domingos; Silva, Eliézer; Pardini, Andreia; Assuncao, Murillo Santucci Cesar de

doi:10.1590/S1679-45082015AO3313

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Original Article • EINSEinstein (São Paulo) 13 (3) • Jul-Sep 2015 • https://doi.org/10.1590/S1679-45082015AO3313 copy

Comparative analysis of survival between elderly and non-elderly severe sepsis and septic shock resuscitated patients

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective

To compare outcomes between elderly (≥65 years old) and non-elderly (<65 years old) resuscitated severe sepsis and septic shock patients and determine predictors of death among elderly patients.

Methods

Retrospective cohort study including 848 severe sepsis and septic shock patients admitted to the intensive care unit between January 2006 and March 2012.

Results

Elderly patients accounted for 62.6% (531/848) and non-elderly patients for 37.4% (317/848). Elderly patients had a higher APACHE II score [22 (18-28)versus 19 (15-24); p<0.001], compared to non-elderly patients, although the number of organ dysfunctions did not differ between the groups. No significant differences were found in 28-day and in-hospital mortality rates between elderly and non-elderly patients. The length of hospital stay was higher in elderly compared to non-elderly patients admitted with severe sepsis and septic shock [18 (10-41)versus 14 (8-29) days, respectively; p=0.0001]. Predictors of death among elderly patients included age, site of diagnosis, APACHE II score, need for mechanical ventilation and vasopressors.

Conclusion

In this study population early resuscitation of elderly patients was not associated with increased in-hospital mortality. Prospective studies addressing the long-term impact on functional status and quality of life are necessary.

Aged; Sepsis; Shock, septic; Shock; Resuscitation; Multiple organ failure; Fluid therapy; Vasoconstrictor agents

Characteristic	<65 years 317 (37.4%) n (%)	≥65 years 531 (62.6%) n (%)	p value
Male sex	178 (56.2)	310 (58.4)	0.566
Underlying disease
Systemic hypertension	89 (28.1)	280 (52.9)	<0.001
Diabetes mellitus	69 (21.8)	173 (32.7)	0.001
Neoplasms	73 (23.0)	146 (27.6)	0.142
Congestive heart failure	12 (3.8)	73 (13.8)	<0.001
Coronary insufficiency	18 (5.7)	72 (13.6)	<0.001
COPD	7 (2.2)	67 (12.7)	<0.001
Chronic renal failure	10 (3.2)	44 (8.3)	0.003
Chronic renal failure RRT	12 (3.8)	30 (5.7)	0.255
Liver cirrhosis	60 (18.9)	20 (3.8)	<0.001
Solid organ transplantation	66 (20.8)	14 (2.6)	<0.001
HIV	3 (0.9)	1 (0.2)	0.151
Number of comorbid conditions			<0.001
0	85 (26.8)	75 (14.1)
1	109 (34.4)	161 (30.3)
2	80 (25.2)	168 (31.7)
≥3	43 (13.6)	127 (23.9)
Source of infection
Respiratory tract	144 (45.4)	307 (57.8)	<0.001
Urinary tract	51 (16.1)	85 (16.0)	1.000
Abdominal	84 (26.5)	77 (14.5)	<0.001
Skin and soft tissue	9 (2.8)	25 (4.7)	0.208
Others	12 (3.8)	20 (3.8)	1.000
Bloodstream	13 (4.1)	10 (1.9)	0.078
Unknown	4 (1.3)	7 (1.3)	1.000
Site of diagnosis, n (%)
Emergency department	155 (48.9)	270 (50.8)	0.619
Hospital floor	107 (33.8)	104 (19.6)	<0.001
Intermediary care	18 (5.7)	93 (17.5)	<0.001
Intensive care unit	33 (10.4)	61 (11.5)	0.653
Other	4 (1.3)	3 (0.6)	0.434

Characteristic	<65 years 317 (37.4%)	≥65 years 531 (62.6%)	p value
APACHE II score, median [IQR]	19 [15-24]	22 [18-28]	<0.001
Arterial lactate (mmol/L), median [IQR]	2.4 [1.3-4.1]	2.2 [1.4-3.6]	0.285
Severe sepsis, n (%)	141 (44.5)	230 (43.3)	0.775
Septic shock, n (%)	176 (55.5)	301 (56.7)
Clinical presentation, n (%)
Hypotension	229 (72.2)	384 (72.3)	1.000
Lactate ≥4.0mmol/L	86 (27.7)	101 (19.7)	0.008
Number of organ dysfunctions, median [IQR]	2 [2-4]	3 [2-3]	0.829
Organ dysfunction, n (%)
Circulatory	230 (72.6)	361 (68.0)	0.165
Respiratory	181 (57.1)	325 (61.2)	0.248
Renal	136 (42.9)	205 (38.6)	0.220
CNS	92 (29.0)	181 (34.1)	0.130
Hepatic	19 (6.0)	17 (3.2)	0.055
Metabolic	106 (33.4)	177 (33.3)	1.000
Hematologic	93 (29.3)	130 (24.5)	0.126

Outcomes	<65 years 317 (37.4%)	≥65 years 531 (62.6%)	p value
Severe sepsis
Mortality day 28, n (%)	13/135 (9.6)	33/217 (15.2)	0.146
In-hospital mortality, n (%)	20/141 (14.2)	47/230 (20.4)	0.164
Length of ICU stay (days), median [IQR]	3 [2-7]	3 [1-9]	0.583
Length of hospital stay (days), median [IQR]	12 [6-24]	15 [8-34]	0.027
Septic shock
Mortality day 28, nº (%)	63/166 (38.0)	101/290 (34.8)	0.543
In-hospital mortality, nº (%)	70/176 (39.8)	134/301(44.5)	0.338
Length of ICU stay (days), median [IQR]	5 [2-12]	6 [3-13]	0.146
Length of hospital stay (days), median [IQR]	18 [9-36]	21 [11-47]	0.016
Severe sepsis and septic shock
Mortality day 28, n (%)	76/301 (25.2)	134/507 (26.4)	0.740
In-hospital mortality, n (%)	90/317 (28.4)	181/531 (34.1)	0.094
Length of ICU stay (days), median [IQR]	4 [2-10]	5 [2-11]	0.141
Length of hospital stay (days), median [IQR]	14 [8-29]	18 [10-41]	0.001

Characteristics	Univariate analysis			Multivariate analysis
Characteristics	OR	95%CI	p value	OR	95%CI	p value
Male sex	0.82	0.61-1.10	0.182	0.68	0.48-0.97	0.032
Site of diagnosis
Emergency department	1.00
Hospital floor	3.10	2.14-4.48	<0.001	2.74	1.78-4.22	<0.001
Intermediary care	4.93	3.15-7.71	<0.001	4.39	2.63-7.35	<0.001
Intensive care unit	5.78	3.59-9.31	<0.001	3.64	2.04-6.50	<0.001
Liver cirrhosis	2.62	1.65-4.18	<0.001	2.13	1.22-3.72	0.008
Urinary tract infection	0.30	0.18-0.49	<0.001	0.40	0.21-0.75	0.040
APACHE II score	1.11	1.08-1.13	<0.001	1.08	1.05-1.11	<0.001
Arterial lactate	1.18	1.12-1.25	<0.001	1.14	1.06-1.22	<0.001
Number of organ dysfunction	1.56	1.38-1.76	<0.001	1.21	1.04-1.40	0.012
Mechanical ventilation	4.94	3.62-6.73	<0.001	1.89	1.29-2.78	0.001

Characteristics	Univariate analysis			Multivariate analysis
Characteristics	OR	95%CI	p value	OR	95%CI	p value
Age, years	1.04	1.02-1.07	<0.001	1.04	1.01-1.07	0.003
Male sex	0.69	0.48-1.00	0.048	0.61	0.40-0.94	0.023
Site of diagnosis
Emergency department	1.00
Hospital floor	2.71	1.67-4.39	<0.001	2.40	1.37-4.20	0.002
Intermediary care	3.82	2.31-6.30	<0.001	3.71	2.07-6.65	<0.001
Intensive care unit	4.12	2.31-7.37	<0.001	3.07	1.52-6.20	0.002
Systemic hypertension	0.63	0.44-0.90	0.012	0.56	0.36-0.86	0.009
Diabetes mellitus	0.58	0.39-0.87	0.008	0.58	0.36-0.94	0.025
Abdominal infection	0.69	0.40-1.18	0.174	0.50	0.27-0.95	0.034
APACHE II score	1.09	1.06-1.12	<0.001	1.06	1.03-1.10	<0.001
Mechanical ventilation	5.11	3.47-7.52	<0.001	2.18	1.36-3.52	0.001
Vasopressor administration	3.25	2.17-4.85	<0.001	1.98	1.24-3.18	0.005

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[1] Corresponding author: Murillo Santucci Cesar de Assuncao – Avenida Albert Einstein, 627/701, 5th floor – Morumbi – Zip code: 05652-900 – São Paulo, SP, Brazil – Phone: (55 11) 2151-0520 E-mail:murillo.assuncao@einstein.br