Epidemiología, diagnóstico y tratamiento de la sepsis severa en Uruguay
Un estudio multicéntrico prospectivo
Palabras clave:
SEPSIS, CHOQUE SÉPTICOResumen
Objetivo: conocer las características epidemiológicas de pacientes que ingresan por sepsis severa (SS) y shock séptico (ShS); valorar la implementación de recomendaciones de la campaña Sobrevivir a las Sepsis (CSS) y determinar variables asociadas con mal pronóstico vital.
Diseño: estudio prospectivo, observacional, cohorte única, multicéntrico, durante un año (setiembre 2011 - agosto 2012). Ámbito: cinco centros de Montevideo, del subsector público y privado con cobertura de 800.000 habitantes.
Pacientes y métodos: 153 pacientes que ingresaron con diagnóstico de SS y ShS a las unidades de cuidados intensivos (UCI) de forma consecutiva. Variables de interés principales: aquellas relacionadas con características del paciente y episodio de sepsis, medidas diagnósticas y terapéuticas según la CSS en las primeras 48 horas, y pronósticas en UCI, hospital y a los seis meses.
Resultados: se incluyeron 153 pacientes, la mediana de edad fue 68 años, la de Acute Physiology and Chronic Health Evaluation (APACHE II) fue de 24; 73,9% recibieron asistencia respiratoria mecánica (ARM), con una mediana de 8 días. La mediana de estadía en CTI fue de 12 y la de estadía hospitalaria fue de 19 días. De los episodios de SS, ShS, 69,3% de los casos fue comunitario; 77,8% presentó shock, y 37,9% inmunodebilidad-inmunocompromiso. Predominó la sepsis de origen respiratorio en 30,1%, se aisló microorganismos en 64,1%, siendo bacterianas 95,9%. La mortalidad en CTI fue 49,7%, hospitalaria 54,9% y a seis meses 58,8%. Se asociaron a mayor mortalidad hospitalaria: edad, APACHE II, inmunodebilidad-compromiso, demoras de ingreso a UCI e inicio de antimicrobianos y balance positivo.
Conclusiones: los pacientes ingresan a UCI con formas severas o estado biológico comprometido. Existen demoras y limitaciones en el diagnóstico y terapéutica inicial, situaciones que se asocian a mayor mortalidad hospitalaria.
Citas
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(3) Estenssoro E, González F, Laffaire E, Canales H, Sáenz G, Reina R, et al. Shock on admission day is the best predictor of prolonged mechanical ventilation in the ICU. Chest 2005; 127(2):598-603.
(4) Rieppi G, Nin N, Lombardi R. Primer estudio epidemiológico de sepsis severa en Uruguay. Paciente Crít (Uruguay) 2006; 17:52-3.
(5) Correa H, Bagnulo H, Hiriart JC, Bagattini JC. Sepsis: análisis de 80 casos en un Centro de Tratamiento Intensivo. Tórax. 1975; 24:168-81.
(6) Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348(16):1546-54.
(7) Wang HE, Shapiro NI, Angus DC, Yealy DM. National estimates of severe sepsis in United States emergency departments. Crit Care Med 2007; 35(8):1928-36.
(8) Levy MM, Artigas A, Phillips GS, Rhodes A, Beale R, Osborn T, et al. Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study. Lancet Infect Dis 2012; 12(12):919-24.
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(16) Heyland DK, Hopman W, Coo H, Tranmer J, McColl MA. Long-term health-related quality of life in survivors of sepsis. Short Form 36: a valid and reliable measure of health-related quality of life. Crit Care Med 2000; 28(11) :3599-605.
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(20) van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345(19):1359-67.
(21) Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, et al; Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344(10):699-709.
(22) Annane D, Sébille V, Charpentier C, Bollaert PE, François B, Korach JM, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288(7):862-71.
(23) Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1):296-327.
(24) Barochia AV, Cui X, Vitberg D, Suffredini AF, O’Grady NP, Banks SM, et al. Bundled care for septic shock: an analysis of clinical trials. Crit Care Med 2010; 38(2):668-78.
(25) Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, et al; Surviving Sepsis Campaign. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med 2010; 38(2):367-74.
(26) Eichacker PQ, Natanson C, Danner RL. Surviving sepsis: practice guidelines, marketing campaigns, and Eli Lilly. N Engl J Med 2006; 355(16):1640-2.
(27) Marik PE. Early management of severe sepsis: concepts and controversies. Chest 2014; 145(6):1407-18.
(28) Palencia Herrejón E, Bueno García B. Nuevas guías de práctica clínica de la «Campaña sobrevivir a la sepsis»: lectura crítica. Med Intensiva 2013; 37(9):600-4.
(29) American College of Chest Physicians. Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992; 20(6):864-74.
(30) McCabe WR, Jackson GG. Gram negative bacteriemia I: etiology and ecology. Arch Intern Med 1962; 110(6):847-55.
(31) Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008; 36(5):309-32.
(32) León Gil C, García-Castrillo Riesgo L, Moya Mir MS, Artigas Raventós A, Borges Sa M, Candel González FJ, et al. Documento de consenso (SEMES-SEMICYUC): recomendaciones del manejo diagnóstico-terapéutico inicial y multidisciplinario de la sepsis grave en los servicios de urgencias hospitalarios. Emergencias 2007; 19(5):260-72.
(33) Society of Critical Care Medicine, Surviving Sepsis Campaign Executive Committee. Severe sepsis bundles. Disponible en: http://www.survivingsepsis.org/Bundles/Pages/default.aspx. (Consulta: 15 diciembre 2010).
(34) Blanco J, Muriel-Bombín A, Sagredo V, Taboada F, Gandía F, Tamayo L, et al; Grupo de Estudios y Análisis en Cuidados Intensivos. Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study. Crit Care 2008; 12(6):R158.
(35) Young MP, Gooder VJ, McBride K, James B, Fisher ES. Inpatient transfers to the intensive care unit: delays are associated with increased mortality and morbidity. J Gen Intern Med 2003; 18(2):77-83.
(36) Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP; DELAY-ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007; 35(6):1477-83.
(37) Esteban A, Frutos-Vivar F, Ferguson ND, Peñuelas O, Lorente JA, Gordo F, et al. Sepsis incidence and outcome: contrasting the intensive care unit with the hospital ward. Crit Care Med 2007; 35(5):1284-9.
(38) Ferrer R, Artigas A, Levy MM, Blanco J, González-Díaz G, Garnacho-Montero J, et al; Edusepsis Study Group. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA 2008; 299(19):2294-303.
(39) Noritomi DT, Ranzani OT, Monteiro MB, Ferreira EM, Santos SR, Leibel F, et al. Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study. Intensive Care Med 2014; 40(2):182-91.
(2) Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29(7):1303-10.
(3) Estenssoro E, González F, Laffaire E, Canales H, Sáenz G, Reina R, et al. Shock on admission day is the best predictor of prolonged mechanical ventilation in the ICU. Chest 2005; 127(2):598-603.
(4) Rieppi G, Nin N, Lombardi R. Primer estudio epidemiológico de sepsis severa en Uruguay. Paciente Crít (Uruguay) 2006; 17:52-3.
(5) Correa H, Bagnulo H, Hiriart JC, Bagattini JC. Sepsis: análisis de 80 casos en un Centro de Tratamiento Intensivo. Tórax. 1975; 24:168-81.
(6) Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348(16):1546-54.
(7) Wang HE, Shapiro NI, Angus DC, Yealy DM. National estimates of severe sepsis in United States emergency departments. Crit Care Med 2007; 35(8):1928-36.
(8) Levy MM, Artigas A, Phillips GS, Rhodes A, Beale R, Osborn T, et al. Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study. Lancet Infect Dis 2012; 12(12):919-24.
(9) Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, et al; EPIC II Group of Investigators. International study of the prevalence and outcomes of infection in intensive care units. JAMA 2009; 302(21):2323-9.
(10) Beale R, Reinhart K, Brunkhorst FM, Dobb G, Levy M, Martin G, et al; PROGRESS Advisory Board. Promoting Global Research Excellence in Severe Sepsis (PROGRESS): lessons from an international sepsis registry. Infection 2009; 37(3):222-32.
(11) Machado FR, Mazza BF. Improving mortality in sepsis: analysis of clinical trials. Shock 2010; 34(Suppl 1):54-8.
(12) Rodríguez F, Barrera L, De La Rosa G, Dennis R, Dueñas C, Granados M, et al. The epidemiology of sepsis in Colombia: a prospective multicenter cohort study in ten university hospitals. Crit Care Med 2011; 39(7):1675-82.
(13) Dougnac A, Mercado M, Cornejo R, Cariaga M, Hernández G, Andresen M, et al; Grupo Chileno del Estudio de la Sepsis. Prevalencia de sepsis grave en las Unidades de Cuidado Intensivo: primer estudio nacional multicéntrico. Rev Méd Chile 2007; 135(5):620-30.
(14) Iñigo J, Sendra J.M, Díaz R, Bouza C, Sarría-Santamera A. Epidemiología y costes de la sepsis grave en Madrid: estudio de altas hospitalarias. Med Intensiva 2006; 30(5):197- 203.
(15) Burchardi H, Schneider H. Economic aspects of severe sepsis: a review of intensive care unit costs, cost of illness and cost effectiveness of therapy. Pharmacoeconomics 2004; 22(12):793-813.
(16) Heyland DK, Hopman W, Coo H, Tranmer J, McColl MA. Long-term health-related quality of life in survivors of sepsis. Short Form 36: a valid and reliable measure of health-related quality of life. Crit Care Med 2000; 28(11) :3599-605.
(17) Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest 1999; 115(2):462-74.
(18) 18. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342(18):1301-8.
(19) 19. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al; Early Goal-Directed Therapy Collaborative Group. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345(19):1368-77.
(20) van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345(19):1359-67.
(21) Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, et al; Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344(10):699-709.
(22) Annane D, Sébille V, Charpentier C, Bollaert PE, François B, Korach JM, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002; 288(7):862-71.
(23) Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36(1):296-327.
(24) Barochia AV, Cui X, Vitberg D, Suffredini AF, O’Grady NP, Banks SM, et al. Bundled care for septic shock: an analysis of clinical trials. Crit Care Med 2010; 38(2):668-78.
(25) Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, et al; Surviving Sepsis Campaign. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med 2010; 38(2):367-74.
(26) Eichacker PQ, Natanson C, Danner RL. Surviving sepsis: practice guidelines, marketing campaigns, and Eli Lilly. N Engl J Med 2006; 355(16):1640-2.
(27) Marik PE. Early management of severe sepsis: concepts and controversies. Chest 2014; 145(6):1407-18.
(28) Palencia Herrejón E, Bueno García B. Nuevas guías de práctica clínica de la «Campaña sobrevivir a la sepsis»: lectura crítica. Med Intensiva 2013; 37(9):600-4.
(29) American College of Chest Physicians. Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992; 20(6):864-74.
(30) McCabe WR, Jackson GG. Gram negative bacteriemia I: etiology and ecology. Arch Intern Med 1962; 110(6):847-55.
(31) Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008; 36(5):309-32.
(32) León Gil C, García-Castrillo Riesgo L, Moya Mir MS, Artigas Raventós A, Borges Sa M, Candel González FJ, et al. Documento de consenso (SEMES-SEMICYUC): recomendaciones del manejo diagnóstico-terapéutico inicial y multidisciplinario de la sepsis grave en los servicios de urgencias hospitalarios. Emergencias 2007; 19(5):260-72.
(33) Society of Critical Care Medicine, Surviving Sepsis Campaign Executive Committee. Severe sepsis bundles. Disponible en: http://www.survivingsepsis.org/Bundles/Pages/default.aspx. (Consulta: 15 diciembre 2010).
(34) Blanco J, Muriel-Bombín A, Sagredo V, Taboada F, Gandía F, Tamayo L, et al; Grupo de Estudios y Análisis en Cuidados Intensivos. Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study. Crit Care 2008; 12(6):R158.
(35) Young MP, Gooder VJ, McBride K, James B, Fisher ES. Inpatient transfers to the intensive care unit: delays are associated with increased mortality and morbidity. J Gen Intern Med 2003; 18(2):77-83.
(36) Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP; DELAY-ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007; 35(6):1477-83.
(37) Esteban A, Frutos-Vivar F, Ferguson ND, Peñuelas O, Lorente JA, Gordo F, et al. Sepsis incidence and outcome: contrasting the intensive care unit with the hospital ward. Crit Care Med 2007; 35(5):1284-9.
(38) Ferrer R, Artigas A, Levy MM, Blanco J, González-Díaz G, Garnacho-Montero J, et al; Edusepsis Study Group. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA 2008; 299(19):2294-303.
(39) Noritomi DT, Ranzani OT, Monteiro MB, Ferreira EM, Santos SR, Leibel F, et al. Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study. Intensive Care Med 2014; 40(2):182-91.
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2016-09-30
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Bertullo M, Carbone N, Brandes M, Silva M, Meiss H, Tejera D, et al. Epidemiología, diagnóstico y tratamiento de la sepsis severa en Uruguay: Un estudio multicéntrico prospectivo. Rev. Méd. Urug. [Internet]. 30 de septiembre de 2016 [citado 21 de diciembre de 2024];32(3):178-89. Disponible en: https://revista.rmu.org.uy/index.php/rmu/article/view/166
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