VANCOUVER--Even though pulmonary dysfunction often occurs early during the course of sepsis, the condition is not predictive of a poor prognosis, according to data from a large prospective, multicenter study.[1] Instead, increased mortality is associated with early failure of nonpulmonary organ systems–particularly the neurologic, coagulation, and renal systems.

The study was designed to determine whether specific changes in organ function are related to a poor outcome in patients with sepsis. James A. Russell, MD, and colleagues used a simple scoring system,[2] which gauges the extent of dysfunction in six organ systems, to investigate the changes in organ function from the onset of sepsis to day 3 in 287 patients. The information was also used to determine which early changes in organ function predict 30–day mortality.

“Our study was not designed to develop a new scoring system to predict outcomes, such as mortality. Rather, it describes the relationship between scores and outcome to provide a rationale for use of the scoring system … in clinical trials of new therapies,” said Dr. Russell, who is Chair of the Department of Medicine at St. Paul’s Hospital and Professor of Medicine at the University of British Columbia, in Vancouver. “We reasoned that if the scoring system describes the morbidity of sepsis syndrome, then it should have a relationship to mortality, because multiple–system organ dysfunction is such a common mode of death in patients who have sepsis syndrome.”

PREDICTORS OF MORTALITY

Although clinically significant pulmonary dysfunction was found to be the most common type of organ failure during the onset of sepsis, the incidence of early pulmonary dysfunction did not differ among survivors and nonsurvivors. In contrast, clinically significant dysfunction of the cardiovascular, neurologic, coagulation, renal, or hepatic systems developed less frequently at the onset of sepsis but was much more strongly associated with the 30–day mortality rate. The severity of organ dysfunction at the onset of sepsis correlated directly with 30–day mortality for all systems except the lungs.

“The lack of relation between pulmonary dysfunction and mortality could be due to improvements in respiratory support, especially for severe acute respiratory distress syndrome (ARDS),” said Dr. Russell, noting that observational data from the University of Washington suggest that mortality from ARDS may be decreasing.[3]

IMPLICATIONS FOR CARE

“These findings give practical information to clinicians,” Dr. Russell added. “[They] show that the pattern—as well as the number—of organs failing in sepsis is an important indicator of disease progression and response to treatment. Intensivists tend to focus on cardiovascular and respiratory failure, especially at the onset of sepsis. But the focus over the first days may have to shift to carefully following, and perhaps designing preventive treatment for, these other types (ie, neurologic, coagulation, and renal) of organ dysfunction.”

--Kristin Della Volpe

References
1. Russell JA, Singer J, Bernard GR, et al. Changing pattern of organ dysfunction in early human sepsis is related to mortality. Crit Care Med. 2000;28:3405– 3411.

2. Hebert P, Drummond AJ, Singer J, et al. A simple multiple system organ failure scoring system predicts mortality of patients who have sepsis syndrome. Chest. 1993;104:230– 235.

3. Milberg JA, Davis DR, Steinberg KP, Hudson LD. Improved survival of patients with acute respiratory distress syndrome (ARDS): 1983-1993. JAMA. 1995;273:306– 309.

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