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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
ARTICLE HIGHLIGHTS
Research background
The Sepsis 3.0 criteria for sepsis and septic shock have been extensively used in the definition of severe patients, admitted to hospital care and intensive care, in order to adequately define a subset of patients with poor prognosis and higher mortality rates.
Since its publication in 2016, its use has been presented as a good diagnostic tool to define these patients and to promptly initiate organic support. Coronavirus disease 2019 (COVID-19) patients present a strong association with life-threatening organ dysfunction due to septic shock and frequently require intensive care unit (ICU) admission and organ support.
Research motivation
COVID-19 patients frequently lack hyperlactatemia, a necessary clinical criteria to define septic shock using the Septic Shock 3.0 criteria. Therefore, this could potentially lead to an unrecognized subset of these patients who have a high illness severity and mortality risk, and are inaccurately classified as having sepsis.
Research objectives
This study aimed to identify the proportion of patients with severe COVID-19 with vasopressor requirements without hyperlactatemia and describe their clinical outcomes and mortality rate.
Research methods
A single-center prospective observational cohort study was conducted in a tertiary hospital in Portugal, analyzing adult patients, admitted to the ICU, with COVID-19 pneumonia. Data collection was extensive, providing data on comorbidities, clinical status, severity indices, respiratory, hemodynamic, and renal dysfunction and the outcome of these COVID-19 patients.
Research results
Twenty-two percent of the analyzed COVID-19 patients were found to have persistent hypotension despite adequate volume resuscitation, requiring vasopressor support, and without hyperlactatemia. This "Vasoplegic Shock" group was found to have high 28-day and hospital mortality rates, and few vasopressor-free days and ventilator-free days, without significant differences to those in the "Septic Shock" group, but significantly different to those in the Sepsis group. Multivariable logistic regression identified the maximum dose of vasopressor therapy used and serum lactate level as the major explanatory variables of mortality rates. However, the highest AUROC was for the maximum vasopressor therapy dosage used when compared to serum lactate level.
Research conclusions
The Sepsis 3.0 criteria for septic shock may exclude approximately one-third of patients with similar clinical severity, poor outcomes, and mortality rate, which should be equally addressed.
Research perspectives
Further studies are needed to identify a subset of COVID-19 patients, who were not initially admitted to the ICU, despite persistent hypotension with vasopressor requirements, and describe their clinical course and outcomes, further demonstrating a potential need to redefine the septic shock criteria in COVID-19 patients in order to maximize early recognition and prompt adequate surveillance and support.
