Association between trends in clinical variables and outcome in intensive care patients with faecal peritonitis: analysis of the GenOSept cohort.
BACKGROUND
Patients admitted to intensive care following surgery for faecal peritonitis present particular challenges in terms of clinical management and risk assessment. Collaborating surgical and intensive care teams need shared perspectives on prognosis. We aimed to determine the relationship between dynamic assessment of trends in selected variables and outcomes.


METHODS
We analysed trends in physiological and laboratory variables during the first week of intensive care unit (ICU) stay in 977 patients at 102 centres across 16 European countries. The primary outcome was 6-month mortality. Secondary endpoints were ICU, hospital and 28-day mortality. For each trend, Cox proportional hazards (PH) regression analyses, adjusted for age and sex, were performed for each endpoint.


RESULTS
Trends over the first 7 days of the ICU stay independently associated with 6-month mortality were worsening thrombocytopaenia (mortality: hazard ratio (HR) = 1.02; 95% confidence interval (CI), 1.01 to 1.03; P < 0.001) and renal function (total daily urine output: HR =1.02; 95% CI, 1.01 to 1.03; P < 0.001; Sequential Organ Failure Assessment (SOFA) renal subscore: HR = 0.87; 95% CI, 0.75 to 0.99; P = 0.047), maximum bilirubin level (HR = 0.99; 95% CI, 0.99 to 0.99; P = 0.02) and Glasgow Coma Scale (GCS) SOFA subscore (HR = 0.81; 95% CI, 0.68 to 0.98; P = 0.028). Changes in renal function (total daily urine output and renal component of the SOFA score), GCS component of the SOFA score, total SOFA score and worsening thrombocytopaenia were also independently associated with secondary outcomes (ICU, hospital and 28-day mortality). We detected the same pattern when we analysed trends on days 2, 3 and 5. Dynamic trends in all other measured laboratory and physiological variables, and in radiological findings, changes in respiratory support, renal replacement therapy and inotrope and/or vasopressor requirements failed to be retained as independently associated with outcome in multivariate analysis.


CONCLUSIONS
Only deterioration in renal function, thrombocytopaenia and SOFA score over the first 2, 3, 5 and 7 days of the ICU stay were consistently associated with mortality at all endpoints. These findings may help to inform clinical decision making in patients with this common cause of critical illness.
Intensive Care Unit, Whiston Hospital, Prescot, Warrington Road, Prescot, Merseyside, L35 5DR, UK. ascanio.tridente@doctors.org.uk.|Department of Infection and Immunity, The Medical School, University of Sheffield, Beech Hill Rd, Sheffield, South Yorkshire, S10 2RX, Sheffield, UK. ascanio.tridente@doctors.org.uk.
Ascanio
A
Tridente
The Wellcome Trust Centre for Human Genetics, University of Oxford, University Offices, Wellington Square, Oxford, OX1 2JD, Oxford, UK. gclarke@well.ox.ac.uk.
Geraldine M
GM
Clarke
Intensive Care Unit, Royal Berkshire Hospital, Craven Road, RG1 5AN, Reading, UK. apwalden@hotmail.com.
Andrew
A
Walden
Imperial College, SW7 2AZ, London, UK. anthony.gordon@imperial.ac.uk.
Anthony C
AC
Gordon
Intensive Care Unit, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, UK. icugeneticresearch@orh.nhs.uk.
Paula
P
Hutton
Medical Intensive Care Unit, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. jean-daniel.chiche@cch.aphp.fr.
Jean-Daniel
JD
Chiche
Imperial College, SW7 2AZ, London, UK. paul.holloway@imperial.ac.uk.
Paul A H
PA
Holloway
Department of Infection and Immunity, The Medical School, University of Sheffield, Beech Hill Rd, Sheffield, South Yorkshire, S10 2RX, Sheffield, UK. g.h.mills@sheffield.ac.uk.|Intensive Care Unit, Sheffield Teaching Hospitals NHS Trust, Northern General Hospital, Herries Road, South Yorkshire, S5 7AU, Sheffield, UK. g.h.mills@sheffield.ac.uk.
Gary H
GH
Mills
Department of Anaesthesia and Critical Care, School of Clinical and Experimental Medicine, University of Birmingham, Office 1, Ground Floor East, old Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2TH, UK. j.f.bion@bham.ac.uk.
Julian
J
Bion
Department of Anaesthesiology and Pain Medicine, University Hospital Inselspital, Bern, and University of Bern, Bern, Switzerland. frank.stueber@insel.ch.
Frank
F
Stüber
Intensive Care Unit, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, UK. cgarrard@mac.com.
Christopher
C
Garrard
Barts and The School of Medicine and Dentistry, Queen Mary University of London, Turner Street, London, E1 2AD, UK. c.j.hinds@qmul.ac.uk.
Charles
C
Hinds
D000368:Aged; D015331:Cohort Studies; D003422:Critical Care / Q000639:trends*; D005060:Europe / Q000453:epidemiology; D005243:Feces; D005260:Female; D006760:Hospitalization / Q000639:trends*; D006801:Humans; D007362:Intensive Care Units / Q000639:trends*; D008297:Male; D008875:Middle Aged; D010538:Peritonitis / Q000175:diagnosis* / Q000378:metabolism / Q000401:mortality*; D018805:Sepsis / Q000175:diagnosis / Q000378:metabolism / Q000401:mortality; D016896:Treatment Outcome