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©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
Septic shock 3.0 criteria application in severe COVID-19 patients: An unattended sepsis population with high mortality risk
José Pedro Cidade, LM Coelho, Vasco Costa, Rui Morais, Patrícia Moniz, Luís Morais, Pedro Fidalgo, António Tralhão, Carolina Paulino, David Nora, Bernardino Valério, Vítor Mendes, Camila Tapadinhas, Pedro Povoa
José Pedro Cidade, Polyvalent Intensive Care Unit, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisboa 1449-005, Portugal
LM Coelho, Polyvalent Intensive Care Unit, Hospital Sao Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon 1449-005, Portugal
Vasco Costa, Rui Morais, Patrícia Moniz, Luís Morais, Pedro Fidalgo, António Tralhão, Carolina Paulino, David Nora, Bernardino Valério, Camila Tapadinhas, Polyvalent Intensive Care Unit, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon 1449-005, Portugal
Vítor Mendes, Polyvalent Intesive Care Unit, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon 1449-005, Portugal
Pedro Povoa, Polyvalent Intens Care Unit; NOVA Medical School, Hospital Sao Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon 1449-005, Portugal
Author contributions: Cidade JP, Coelho L, Costa V, Morais R, Moniz P, Morais L, Fidalgo P, Tralhão A, Paulino C, Nora D, Valério B, Mendes V, Tapadinhas C, and Póvoa P contributed to conceptualization, data curation and statistical analysis; Cidade JP, Coelho L; and Póvoa P designed the research; Cidade JP wrote the paper; Coelho L and Póvoa P reviewed and edited the original draft and contributed to project supervision.
Institutional review board statement: The study was approved by the Portuguese National Ethics Committee for Clinical Research (reference REC: 2020_EO_02).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors declare that they have no conflict-of-interest to disclose.
Data sharing statement: The datasets generated and/or analyzed during the current study are not publicly available due to privacy issues but are available from the corresponding author on reasonable request.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: José Pedro Cidade, MD, Doctor, Polyvalent Intensive Care Unit, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Estrada forte alto do duque, Lisboa 1449-005, Portugal. zencidade@gmail.com
Received: November 6, 2021
Peer-review started: November 6, 2021
First decision: January 12, 2022
Revised: January 17, 2022
Accepted: June 24, 2022
Article in press: June 24, 2022
Published online: July 9, 2022
BACKGROUND
Coronavirus disease 2019 (COVID-19) can be associated with life-threatening organ dysfunction due to septic shock, frequently requiring intensive care unit (ICU) admission, respiratory and vasopressor support. Therefore, clear clinical criteria are pivotal for early recognition of patients more likely to need prompt organ support. Although most patients with severe COVID-19 meet the Sepsis-3.0 criteria for septic shock, it has been increasingly recognized that hyperlactatemia is frequently absent, possibly leading to an underestimation of illness severity and mortality risk.
AIM
To identify the proportion of severe COVID-19 patients with vasopressor support requirements, with and without hyperlactatemia, and describe their clinical outcomes and mortality.
METHODS
We performed a single-center prospective cohort study. All adult patients admitted to the ICU with COVID-19 were included in the analysis and were further divided into three groups: Sepsis group, without both criteria; Vasoplegic Shock group, with persistent hypotension and vasopressor support without hyperlactatemia; and Septic Shock 3.0 group, with both criteria. COVID-19 was diagnosed using clinical and radiologic criteria with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive RT-PCR test.
RESULTS
118 patients (mean age 63 years, 87% males) were included in the analysis (n = 51 Sepsis group, n = 26 Vasoplegic Shock group, and n = 41 Septic Shock 3.0 group). SOFA score at ICU admission and ICU length of stay were different between the groups (P < 0.001). Mortality was significantly higher in the Vasoplegic Shock and Septic Shock 3.0 groups when compared with the Sepsis group (P < 0.001) without a significant difference between the former two groups (P = 0.713). The log rank tests of Kaplan-Meier survival curves were also different (P = 0.007). Ventilator-free days and vasopressor-free days were different between the Sepsis vs Vasoplegic Shock and Septic Shock 3.0 groups (both P < 0.001), and similar in the last two groups (P = 0.128 and P = 0.133, respectively). Logistic regression identified the maximum dose of vasopressor therapy used (AOR 1.046; 95%CI: 1.012-1.082, P = 0.008) and serum lactate level (AOR 1.542; 95%CI: 1.055-2.255, P = 0.02) as the major explanatory variables of mortality rates (R2 0.79).
CONCLUSION
In severe COVID-19 patients, the Sepsis 3.0 criteria of septic shock may exclude approximately one third of patients with a similarly high risk of a poor outcome and mortality rate, which should be equally addressed.
Core Tip: Coronavirus disease 2019 (COVID-19) can be associated with life-threatening organ dysfunction due to septic shock, frequently requiring intensive care unit admission, respiratory and vasopressor support. Although most patients with severe COVID-19 meet the Sepsis-3.0 criteria for septic shock, it has been increasingly recognized that hyperlactatemia is frequently absent. Our data clearly show that one third of patients with Sepsis by the Sepsis 3.0 criteria present a risk of poor outcomes and a mortality rate similar to those with Septic Shock, which should be equally addressed.
