title: The impact of delayed biliary decompression and anti-microbial therapy in 260 patients with cholangitis-associated septic shock.
abstract: Cholangitis-associated septic shock carries significant mortality. There is uncertainty regarding the most appropriate time to achieve biliary decompression.
  
  
  
  To determine whether the timing of biliary decompression and anti-microbial therapy affect the survival in cholangitis patients with septic shock.
  
  
  
  Nested retrospective cohort study of all cholangitis-associated septic shock patients (hypotension requiring vasopressors) from an international, multi-centre database between 1996 and 2011.
  
  
  
  Among 260 patients (mean age 69 years, 57% male), overall mortality was 37%. Compared to nonsurvivors (n = 96), survivors (n = 164) had lower mean admission Acute Physiology And Chronic Health Evaluation (APACHE) II (22 vs. 28, P < 0.001) and lower median serum lactate on admission (3.4 vs. 4.6 mmol/L, P < 0.001). Survivors were more likely to receive appropriate anti-microbial therapy earlier (median 2.6 vs. 6.8 h from shock, P < 0.001). Survivors were also more likely to undergo successful biliary decompression earlier (median 8.8 vs. 22 h, P < 0.001). After adjusting for co-variates, APACHE II (odds ratio, OR 1.21 per increment (1.11-1.32), time delay to appropriate anti-microbial therapy [OR 1.15 per hour (1.07-1.25)] and delayed biliary decompression >12 h [OR 3.40 (1.12-10.31)] were all significantly associated with increased mortality (P < 0.04 for all; c-statistic 0.896).
  
  
  
  Patients with septic shock secondary to acute cholangitis have significant mortality. Endoscopic biliary decompression >12 h after the onset of shock and delayed receipt of appropriate anti-microbial therapy were both significantly associated with adverse hospital outcome. This might suggest that early initiation of anti-microbial therapy and urgent biliary decompression (within 12 h) could potentially improve outcomes in this high-risk patient population.
authors: Division of Critical Care Medicine and Gastroenterology/Hepatology, University of Alberta, Edmonton, AB, Canada.|Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada.
authors: C J
authors: CJ
authors: Karvellas
authors: Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada.
authors: J G
authors: JG
authors: Abraldes
authors: Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, AB, Canada.
authors: S
authors: S
authors: Zepeda-Gomez
authors: Division of Gastroenterology, University of Manitoba, Winnipeg, MB, Canada.
authors: D C
authors: DC
authors: Moffat
authors: Section of Infectious Diseases, Surrey Memorial Hospital, Surrey, BC, Canada.
authors: Y
authors: Y
authors: Mirzanejad
authors: Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada.|Department of Microbiology, University of Manitoba, Winnipeg, MB, Canada.
authors: G
authors: G
authors: Vazquez-Grande
authors: Department of Microbiology, University of Manitoba, Winnipeg, MB, Canada.
authors: E K
authors: EK
authors: Esfahani
authors: Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada.|Section of Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada.
authors: A
authors: A
authors: Kumar
mesh_terms: D018806:APACHE; D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D002761:Cholangitis / Q000150:complications*; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012189:Retrospective Studies; D012772:Shock, Septic / Q000209:etiology / Q000628:therapy*; D014662:Vasoconstrictor Agents / Q000008:administration & dosage*
chemical_list: D014662:Vasoconstrictor Agents