Sepsis in MS patients and Intensive care admissions

S

Sepsis (or blood infection) is a dangerous thing. I remember first realising this as a Junior doctor in respiratory medicine, when an audit of pneumonia admissions revealed a mortality of 60%. Sadly, this has not improved by much even with the latest antibiotics. As I rotated through, transplant medicine, haem-oncology, and finally into ICU, I found myself forever pre-occupied with watching the CRP – an acute inflammatory marker, in all of my patients.

There was a hard lesson to be learnt in all this, which was what could be modified (treat early), and what couldn’t be modified (age and co-morbidities) once admitted into hospital – a mental weighing scale of sorts. The SARS-CoV2 for many of us, including myself, was a replay of this but on a wider scale.

See the source image
Source: Express and Star “Intensive care doctors ‘very worried’ about having to choose between patients”

But, as a neurologist and an MS doctor you very rarely come across data specific to your speciality with regards to ITU admissions. Did I know what to expect; may be not, and probably neither do our patients.

This data from Texas collected over a 7 year period with 19,837 ICU admissions with MS during the study period, of which 6244 (31.5%) had sepsis (i.e. a common reason for ICU admission).

The adjusted probability of short-term mortality was 13.4% (95% CI 13.0–13.7) among ICU admissions with sepsis and 3.3% (95% CI 3.2–3.4) among ICU admissions without sepsis (i.e. four-fold higher mortality if you were septic). The predictors of this short-term mortality are detailed below:

Table: Hierarchical multivariate logistic regression analysis of predictors of short-term mortality among ICU admissions with sepsis

Not surprisingly those >65y had a 3-fold greater mortality, as did those with multiple organ failures.

Once a septic patient with MS required both mechanical ventilation and haemodialysis, risk-adjusted short-term mortality was markedly higher across all subgroups, reaching 62.2% among those 65 years or older with 3 or more organ dysfunctions“.

Urinary tract infections (UTIs) had much lower odds of short-term mortality, which is good to know as the incidence of UTIs in MS is very high.

However, I do see a great opportunity for education at all levels of medical care providers and with patients. Firstly, being aware of the risk and early escalation, managing modifiable risk factors (for example alcohol misuse) and careful management of co-morbidities throughout an individuals life.

Abstract

J Crit Care. 2022 Jun;69:153985. doi: 10.1016/j.jcrc.2022.153985. Epub 2022 Jan 11.

The burden of sepsis in critically ill patients with multiple sclerosis: A population-based cohort study

Lavi OudJohn Garza 

Purpose: Multiple sclerosis (MS) is associated with increased risk of critical illness, sepsis, and sepsis-related death, compared to the general population. The epidemiology of sepsis and its impact on the outcomes of critically ill patients with MS are unknown.

Methods: A statewide dataset was used to identify retrospectively ICU admissions in Texas aged ≥18 years with a diagnosis of MS during 2010-2017. The prevalence of sepsis and its impact on inpatient resource utilization and short-term mortality (a combination of in-hospital death or discharge to hospice) were examined.

Results: Among 19,837 ICU admissions with MS, 6244 (31.5%) had sepsis. Compared to ICU admissions without sepsis, those with sepsis were older (aged ≥65 years 34.1% vs 24.1%), less commonly racial/ethnic minority (32.6% vs 35.2%), and had higher mean [SD] Deyo comorbidity index (1.7 [1.8] vs 1.2 [1.7]). On adjusted analyses, sepsis was associated with 42.7% longer hospital length of stay and 26.2% higher total hospital charges. Risk-adjusted short-term mortality among ICU admissions with and without sepsis was 13.4% vs 3.3%, respectively.

Conclusions: Sepsis was present in nearly 1 in 3 ICU admissions with MS, had substantial adverse impact on hospital resource utilization, and was associated with over 4-times higher short-term mortality.

About the author

Neuro Doc Gnanapavan

5 comments

Leave a Reply to Neuro Doc Gnanapavan Cancel reply

  • I am waiting on a date for cancer surgery, total hysterectomy with bilateral salpingo-oophorectomy, robotic. I have all kinds of hell going through my mind, hadn’t considered sepsis.

  • Great post! I believe passionately that there are simple ways to reduce sepsis and pneumonia in hospital setting but not always used.. Many years ago I presented to a group of stakeholders about something very similar: bounce back admissions in the region where I was working. Bounce back admissions occur when a patient is discharged from the emergency room and returns quickly and needs hospitalization. Although a lot of research on this isn’t specific to MS patients, much can be learned From existing research. The US Veteran’s Administration has a great report of what dx, demographics, clinic settings, and gender differences increase bounce back. My recollection was that sepsis was a common reason for a bounce back and reasons given were: time to culture urine and blood and follow up; lack of high fever in older patients; pre admission cognitive impairment dx leads to failure to recognize increase in cognitive impairment from sepsis;, it is difficult to assess a physically weak/frail patient for worsening symptoms;, hearing aids/ dentures/ eyeglasses removed from patient before entering emergency room causes poor communication with patient; and lack of advocate or person familiar with patient in emergency room. A nurse follow up phone call to check on patient was a simple intervention post emergency room exam that helped intervene if patient began to worsen at home or has failed to follow up with regular dr. With re to pneumonia, other research indicated it can be reduced in hospital with dr orders in chart for bed head up 30 degrees and duration (after meals or more) for patients at risk. In addition, a simple sticker on hospital bed indicating what is 30 degree angle because some assistants need visual and will flatten bed when it is changed.

Translate

Categories

Recent Posts

Recent Comments

Archives