Septic shock linked to ‘surprisingly high’ mortality rate among patients with solid tumors
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Among patients with solid tumors, septic shock was associated with a 69.4% 28-day mortality rate, according to a study published in CHEST.
“Even though septic shock is a well-recognized deadly condition, our study, one of the first to use the Sepsis-3 criteria to diagnose septic shock in patients with solid tumors, showed a surprisingly high mortality rate of 69% at 28 days,” Joseph L. Nates, MD, MBA, CMQ, MCCM, professor, deputy chair and patient safety and quality officer in the department of critical care at The University of Texas MD Anderson Cancer Center, told Healio. “Patients with metastatic disease and low functional status prior to becoming infected had the highest risk of dying.”
In a retrospective, longitudinal, single-center cohort study, Nates and colleagues analyzed 271 adults (median age, 62 years; 57.2% men; 53.5% white) with solid tumors who entered the ICU with septic shock — as defined by Sepsis-3 criteria — between April 1, 2016, and March 31, 2019, to determine independent predictors of 28-day mortality in this patient population using a reduced multivariable logistics regression model. Researchers also evaluated patient survival using Kaplan-Meier plots.
Lung cancer was the most frequent underlying malignancy observed in 19.2% of patients, followed by breast (7.7%), pancreatic (7.7%), colorectal (7.4%), renal (5.2%) and prostate (5.2%) cancer. Additionally, 84.5% of patients had metastatic disease.
More than two-thirds (69.4%) of patients died within 28 days, including 74.8% of the patients with respiratory failure, 70.7% of the patients requiring intubation and 65.4% of the patients requiring high-flow oxygen or noninvasive ventilation.
Factors related to greater 28-day morality included metastatic disease (OR = 3.17; 95% CI, 1.43-7.03), respiratory failure (OR = 2.34; 95% CI, 1.15-4.74), elevated lactate levels (OR = 3.19; 95% CI, 1.9-5.36) and an Eastern Cooperative Oncology Group (ECOG) performance score of 3 or 4 (OR = 2.72; 95% CI, 1.33-5.57). According to Nates, severe neutropenia, which is a risk factor for developing sepsis and septic shock, was not related to mortality.
By day 90, 77.1% of patients died. Researchers reported the lowest 90-day survival rates among patients with an ECOG score of 3 or 4 (13.8%), respiratory failure (17.3%) and metastatic disease (19.7%).
“Protocols for early sepsis detection and prompt initiation of therapy, as recommended by the guidelines, should be instituted,” Nates told Healio. “Clinicians managing patients with cancer at risk of developing infections should be aware of the gravity of the progression of severe infections in these patients. Additionally, given the grave prognostic implications of developing septic shock in patients with advanced metastatic disease and low functional status, early goals-of-care discussions should be considered.”
In a subanalysis of 545 patients who did not meet Sepsis-3 criteria but did show sepsis and required vasopressors, researchers found significantly lower ICU mortality rates (25.5% vs. 58.7%), 28-day mortality rates (33.6% vs. 69.4%), hospital mortality rates (34.3% vs. 68.6%) and 90-day mortality rates (49.6% vs. 77.1%; P < .0001 for all) compared with patients who did meet Sepsis-3 criteria.
Of the total cohort who met Sepsis-3 criteria, only 14% of patients were discharged and did not need medical assistance.
“Our study highlights the importance of reporting the most recent diagnostic criteria for septic shock,” Nates told Healio. “This study also raises questions regarding a potential role of the immune-metabolic state of patients with metastatic disease and the surprisingly high mortality rate. Future investigators could help close this gap in knowledge.”
This study by Cuenca and colleagues adds to the literature indicating that further studies that provide an understanding of different critical illness phenotypes, not just those who are extraordinarily sick under Sepsis-3 criteria, will create a more complete understanding of the relationship between septic shock and solid tumors, according to an accompanying editorial by Patrick G. Lyons, MD, and Colleen A. McEvoy, MD, of the John T. Milliken department of medicine at Barnes-Jewish Hospital.
“Critically ill patients with cancer are a heterogeneous population, with outcomes tied to specific syndromes,” Lyons and McEvoy wrote. “However, as we move towards a more sophisticated understanding of critical illness phenotypes, better specification of these groups may yield improved resource utilization, quality of care and patient outcomes. This work from Cuenca et al, in illustrating the limitations of current septic shock criteria among patients with cancer, may represent an important first step toward such a new paradigm.”
For more information:
Joseph L. Nates, MD, MBA, CMQ, MCCM, can be reached at jlnates@mdanderson.org.