Mortality Factors for Severe Septic States in Intensive Care Unit

Summary Background: Sepsis is a life-threatening organ dysfunction caused by an inappropriate host response to an infection. Severe sepsis is a source of morbidity and high mortality in intensive care. The objective of our study was to analyze mortality factors associated with severe sepsis and to describe the epidemiological, clinical and therapeutic aspects. Patients and methods: Monocentric, observational, retrospective study from January 1st, 2015 to June 30th, 2017, concerning the mortality factors of severe sepsis in 40 adult patients in the intensive care unit at Aristide Le Dantec Teaching Hospital in Dakar. Results: Forty-seven cases of severe sepsis were identified out of a total admission of 1242, i.e an incidence of 3.78%. 40 files were exploited. The average age of the patients was 55.75 ± 15.84 years, with extremes of 21 and 86 years. The most common reasons for admission were postoperative gas-gangrene follow-up in 27.5% of patients and septic shock in 25% of patients. The most common infectious foci were cutaneous (27.5%), peritoneal (22.5%) and pulmonary (17.5%). Bacteriologically, there was a predominance of Gram-negative bacilli. Prognostic factors related to mortality were admission from the start for septic shock, presence of hyperthermia at admission, duration of infection before admission, impairment of renal function, and hyperkalemia. Conclusion: Severe sepsis is responsible for significant morbidity and mortality. In our context, the prognostic factors are essentially the duration of the infection, the state of shock and the severe renal failure.


Introduction
Sepsis is a life-threatening organ dysfunction caused by an inappropriate host response to an infection. There is no more distinction between sepsis and severe sepsis [1]. Severe sepsis is a major source of morbidity and mortality in intensive care units. The objectives of our study were to analyze mortality factors related to severe sepsis received in intensive care, epidemiological and therapeutic aspects.

Patients and Methods
This is a monocentric, observational and retrospective study from January 1st, 2015 to June 30th, 2017, dealing with mortality factors for severe sepsis in the multipurpose resuscitation department at Aristide Le Dantec Teaching Hospital in Dakar.
Were included all adult patients who died from severe sepsis whose records were complete. The data was collected from the records and the register of the resuscitation unit.  For evolution data, the causes of death are listed in Table 2.

Discussion
The epidemiology of severe septic syndromes in intensive care is now well known, as are their implications for morbidity and management difficulties. The incidence of severe sepsis is 3.78% in our study. In France, the "Episepsis" survey, conducted in 2001 in a large number of intensive care units, showed that about 15% of patients hospitalized in intensive care, had a severe septic syndrome [2]. It is accepted that the risk of developing a severe infection increases significantly from the age of 60, so that septic shock can be seen at any age, but it is particularly common in the elderly [3]. In our study, the average age was 55.75 years, confirming data from the literature that states a link between mortality and age in septic shock. With regard to gender, the analysis of published data does not find a causal link between sex and mortality [4]. Diabetes was the main field found in our patients. This high frequency could be explained by the delay in patient management and is thought to be responsible for the higher number of admissions for gas gangrene. This delay in management was also reflected in the frequent occurrence of septic shock at admission with a significant relationship with mortality, as well as the duration of infection before admission. The presence of hyperthermia at admission was also correlated with the occurrence of death. Other mortality factors noted in our study were acute renal failure and hyperkalemia. In the SOAP study conducted in Europe on septic patients at resuscitation department, the frequency of acute renal failure was 36%, occurring in 72% of cases during the first 2 days of hospitalization.
The overall mortality at day 60 was 35.7%, with an increase depending on the severity of the acute renal failure: 36% in forms without extrarenal treatment, 41% if need of extrarenal treatment and 52% in case of anuria [5]. There is consensus among experts that prompt extrarenal treatment should be instituted in the following life-threatening situations: hyperkalemia, lysis syndrome, acute pulmonary edema, metabolic acidosis [6,7]. In whereas all the patients had had an initial infectious assessment as soon as admitted. This is due to the long delay in receiving results, which poses a real problem in adapting antibiotic therapy to bacteriological results. However, early and adapted antibiotic therapy is imperative and guarantees better progression during severe sepsis [8]. Inadequate initial antibiotherapy is a source of delay in treatment, lengthening the duration of stay and significant excess mortality [9,10].
Supportive therapies are of great importance in the management of severe sepsis, aiming at the same time at improving the state of health of the patient, but above all at preventing the deleterious complications that may occur during the stay in intensive care; whose lethal potential would only worsen the state of these patients with already poor prognosis.
With this in mind, the study on the Sepsis Survival Campaign and those of indeterminate origin (2%); infections with strict aerobic germs (20%) and yeasts (12%) are also associated with an increased risk of death, unlike Enterobacteriaceae (35%), associated with a comparatively more favorable prognosis. In the same French multi-centric study, mechanical ventilation was the prognostic factor associated with the highest mortality rate [12]. In our study, we had 20% renal failure and 55% ventilated patients. In our series, the prognostic factors of mortality in univariate analysis approached this study by several parameters: demographic (age, direct admission to intensive care, severity of the disease: acute respiratory insufficiency, acute respiratory distress syndrome ARDS, acute renal failure) and therapeutic interventions: mechanical ventilation, use of vasopressive amines.

Conclusion
Severe sepsis is associated with significant morbidity and mortality. In our context, the prognostic factors are essentially the duration of the infection, the state of shock and the severe renal failure. The prognosis can be improved thanks to the early and effective management of identified mortality factors.