Critical care management of severe sepsis and septic shock: a cost-analysis

Background Sepsis treatment has been associated with high costs. Furthermore, both the incidence of sepsis and the severity of illness at presentation appear to be increasing. We estimated healthcare costs related to the treatment of patients with sepsis in the intensive care unit (ICU) and aimed to explain variability in costs between individuals. Methods We performed a prospective cohort study in patients presenting with severe sepsis or septic shock to the ICUs of two tertiary centres in the Netherlands. Resource use was valued using a bottom-up micro-costing approach. Multivariable regression analysis was used to study variability in costs. Results Overall, 651 patients were included, of which 294 presented with septic shock. Mean costs were €2250 (95% CI €2235-€2266) per day and €29,102 (95% CI €26,598-€31,690) per ICU admission. Of the total expenditure, 74% was related to accommodation, personnel, and disposables, 12% to diagnostic procedures, and 14% to therapeutic interventions. Patients with septic shock had higher costs compared with patients with severe sepsis (additional costs: €69 (95% CI €37-€100) per day, and €8355 (95% CI €3400-€13,367) per admission). Site of infection, causative organism, presence of shock, and immunodeficiency were independently associated with costs, but explained only 11% of the total variance. Conclusion Mean costs of sepsis care in the ICU were almost €30,000 per case. As costs were poorly predictable, opportunities for cost savings based on patient profiling upon admission are limited

Occurrence and Risk Factors of Chronic Pain After Critical Illness

Objectives: Occurrence, risk factors, and impact on daily life of chronic pain after critical illness have not been systematically studied. Design: Cohort study. Setting: A tertiary ICU in The Netherlands. Patients: We surveyed patients who had been discharged from our ICU between 2013 and 2016. Three cohorts were defined as follows: 1) ICU survivors; 2) one-year survivors reporting newly-acquired chronic pain; and (3) one-year survivors with pain who lived within 50 km from the study hospital. In cohort 1, we estimated the prevalence of new chronic pain 1 year after ICU discharge and constructed a prediction model for its occurrence incorporating three outcomes: death during follow-up, surviving without new pain, and surviving with newly-acquired pain. In cohort 2, we determined clinical features of pain and its impact on daily life. In cohort 3, we assessed the presence of neuropathic characteristics of pain. Interventions: None. Measurements and Main Results: The three cohorts contained 1,842, 160, and 42 patients, respectively. Estimated occurrence of new chronic pain was 17.7% (95% CI, 15.8-19.8%; n = 242) in 1-year survivors (n = 1,368). Median pain intensity on the numeric rating scale was 4 (interquartile range, 2-6) in the week before survey response, with impact being most evident on activities of daily living, social activities, and mobility. Neuropathic pain features were present in 50% (95% CI, 37-68%) of affected subjects. Among nine predictor variables included in a multinomial model, only female gender and days in ICU with hyperinflammation were associated with pain. Conclusions: Newly-acquired chronic pain is a frequent consequence of critical illness, and its impact on daily life of affected patients is substantial

Occurrence and Risk Factors of Chronic Pain After Critical Illness

Objectives: Occurrence, risk factors, and impact on daily life of chronic pain after critical illness have not been systematically studied. Design: Cohort study. Setting: A tertiary ICU in The Netherlands. Patients: We surveyed patients who had been discharged from our ICU between 2013 and 2016. Three cohorts were defined as follows: 1) ICU survivors; 2) one-year survivors reporting newly-acquired chronic pain; and (3) one-year survivors with pain who lived within 50 km from the study hospital. In cohort 1, we estimated the prevalence of new chronic pain 1 year after ICU discharge and constructed a prediction model for its occurrence incorporating three outcomes: death during follow-up, surviving without new pain, and surviving with newly-acquired pain. In cohort 2, we determined clinical features of pain and its impact on daily life. In cohort 3, we assessed the presence of neuropathic characteristics of pain. Interventions: None. Measurements and Main Results: The three cohorts contained 1,842, 160, and 42 patients, respectively. Estimated occurrence of new chronic pain was 17.7% (95% CI, 15.8-19.8%; n = 242) in 1-year survivors (n = 1,368). Median pain intensity on the numeric rating scale was 4 (interquartile range, 2-6) in the week before survey response, with impact being most evident on activities of daily living, social activities, and mobility. Neuropathic pain features were present in 50% (95% CI, 37-68%) of affected subjects. Among nine predictor variables included in a multinomial model, only female gender and days in ICU with hyperinflammation were associated with pain. Conclusions: Newly-acquired chronic pain is a frequent consequence of critical illness, and its impact on daily life of affected patients is substantial

A pilot study of a novel molecular host response assay to diagnose infection in patients after high-risk gastro-intestinal surgery

PURPOSE: SeptiCyte LAB measures the expression of four host-response RNAs in peripheral blood to distinguish sepsis from sterile inflammation. This study evaluates whether sequential monitoring of this assay has diagnostic utility in patients after esophageal surgery. MATERIALS AND METHODS: Patients who developed a complication within 30 days following esophageal surgery and a random sample of 100 patients having an uncomplicated course. SeptiCyte LAB scores (ranging 0-10 reflecting increasing likelihood of infection) were compared to post-hoc physician adjudication of infection likelihood. RESULTS: Among 370 esophagectomy patients, 120 (32%) subjects developed a complication requiring ICU (re)admission, 63 (53%) of whom could be analyzed. Immediate postoperative SeptiCyte LAB scores were highly variable, yet similar for patients having a complicated and uncomplicated postoperative course (median score of 2.4 (IQR 1.6-3.3) versus 2.2 (IQR 1.3-3), respectively). In a direct comparison of patients developing a confirmed infectious (n = 34) and non-infectious complication (n = 12), addition of SeptiCyte LAB to CRP improved diagnostic discrimination of infectious complications (AUC 0.88 (95%CI 0.77-0.99)) compared to CRP alone (AUC 0.76 (95%CI 0.61-0.91); p = .04). CONCLUSIONS: Sequential measurement of SeptiCyte LAB may have diagnostic value in the monitoring of surgical patients at high risk of postoperative infection, but its clinical performance in this setting needs to be validated

A pilot study of a novel molecular host response assay to diagnose infection in patients after high-risk gastro-intestinal surgery

Purpose: SeptiCyte LAB measures the expression of four host-response RNAs in peripheral blood to distinguish sepsis from sterile inflammation. This study evaluates whether sequential monitoring of this assay has diagnostic utility in patients after esophageal surgery. Materials and methods: Patients who developed a complication within 30 days following esophageal surgery and a random sample of 100 patients having an uncomplicated course. SeptiCyte LAB scores (ranging 0–10 reflecting increasing likelihood of infection) were compared to post-hoc physician adjudication of infection likelihood. Results: Among 370 esophagectomy patients, 120 (32%) subjects developed a complication requiring ICU (re)admission, 63 (53%) of whom could be analyzed. Immediate postoperative SeptiCyte LAB scores were highly variable, yet similar for patients having a complicated and uncomplicated postoperative course (median score of 2.4 (IQR 1.6–3.3) versus 2.2 (IQR 1.3–3), respectively). In a direct comparison of patients developing a confirmed infectious (n = 34) and non-infectious complication (n = 12), addition of SeptiCyte LAB to CRP improved diagnostic discrimination of infectious complications (AUC 0.88 (95%CI 0.77–0.99)) compared to CRP alone (AUC 0.76 (95%CI 0.61–0.91); p = .04). Conclusions: Sequential measurement of SeptiCyte LAB may have diagnostic value in the monitoring of surgical patients at high risk of postoperative infection, but its clinical performance in this setting needs to be validated

Validation of a novel molecular host response assay to diagnose infection in hospitalized patients admitted to the ICU with acute respiratory failure

Objectives: Discrimination between infectious and noninfectious causes of acute respiratory failure is difficult in patients admitted to the ICU after a period of hospitalization. Using a novel biomarker test (SeptiCyte LAB), we aimed to distinguish between infection and inflammation in this population. Design: Nested cohort study. Setting: Two tertiary mixed ICUs in the Netherlands. Patients: Hospitalized patients with acute respiratory failure requiring mechanical ventilation upon ICU admission from 2011 to 2013. Patients having an established infection diagnosis or an evidently noninfectious reason for intubation were excluded. Interventions: None. Measurement and Main Results: Blood samples were collected upon ICU admission. Test results were categorized into four probability bands (higher bands indicating higher infection probability) and compared with the infection plausibility as rated by post hoc assessment using strict definitions. Of 467 included patients, 373 (80%) were treated for a suspected infection at admission. Infection plausibility was classified as ruled out, undetermined, or confirmed in 135 (29%), 135 (29%), and 197 (42%) patients, respectively. Test results correlated with infection plausibility (Spearman's rho 0.332; p < 0.001). After exclusion of undetermined cases, positive predictive values were 29%, 54%, and 76% for probability bands 2, 3, and 4, respectively, whereas the negative predictive value for band 1 was 76%. Diagnostic discrimination of SeptiCyte LAB and C-reactive protein was similar (p = 0.919). Conclusions: Among hospitalized patients admitted to the ICU with clinical uncertainty regarding the etiology of acute respiratory failure, the diagnostic value of SeptiCyte LAB was limited

Validation of a novel molecular host response assay to diagnose infection in hospitalized patients admitted to the ICU with acute respiratory failure

Objectives: Discrimination between infectious and noninfectious causes of acute respiratory failure is difficult in patients admitted to the ICU after a period of hospitalization. Using a novel biomarker test (SeptiCyte LAB), we aimed to distinguish between infection and inflammation in this population. Design: Nested cohort study. Setting: Two tertiary mixed ICUs in the Netherlands. Patients: Hospitalized patients with acute respiratory failure requiring mechanical ventilation upon ICU admission from 2011 to 2013. Patients having an established infection diagnosis or an evidently noninfectious reason for intubation were excluded. Interventions: None. Measurement and Main Results: Blood samples were collected upon ICU admission. Test results were categorized into four probability bands (higher bands indicating higher infection probability) and compared with the infection plausibility as rated by post hoc assessment using strict definitions. Of 467 included patients, 373 (80%) were treated for a suspected infection at admission. Infection plausibility was classified as ruled out, undetermined, or confirmed in 135 (29%), 135 (29%), and 197 (42%) patients, respectively. Test results correlated with infection plausibility (Spearman's rho 0.332; p < 0.001). After exclusion of undetermined cases, positive predictive values were 29%, 54%, and 76% for probability bands 2, 3, and 4, respectively, whereas the negative predictive value for band 1 was 76%. Diagnostic discrimination of SeptiCyte LAB and C-reactive protein was similar (p = 0.919). Conclusions: Among hospitalized patients admitted to the ICU with clinical uncertainty regarding the etiology of acute respiratory failure, the diagnostic value of SeptiCyte LAB was limited