Race, cardiac arrhythmias among risk factors for mechanical ventilation in sepsis

Key takeaways:

• Adults with sepsis who reported being white or of an “other or unknown” race faced a high risk for mechanical ventilation.
• Three comorbidities also raised the risk for mechanical ventilation.

Race, sequential organ failure assessment scores and cardiac arrhythmias are among the factors that raised the risk for mechanical ventilation following sepsis onset, according to results published in American Journal of Critical Care.

Robert E. Freundlich

“Everyday clinicians may see early sepsis almost daily in inpatient settings,” Robert E. Freundlich, MD, MS, MSCI, associate professor in the department of anesthesiology and chief of the anesthesiology informatics research division at Vanderbilt University Medical Center, told Healio. “My hope is that, through an improved understanding of the expected progression of the disease, sepsis that will progress to respiratory failure can be detected earlier and appropriate interventions can be provided in a timely manner.”

In a retrospective observational study using electronic health record data, Freundlich and colleagues evaluated 28,747 adults with sepsis to determine what factors place these patients at risk for needing mechanical ventilation. They also assessed whether these factors change with time through a time-varying Cox model.

Within the total cohort, 3,891 patients (13.5%; mean age, 60 years; 41% women; 81% white) needed to be ventilated 30 days after a sepsis diagnosis or sooner, and half of these patients (n = 2,046; 52.6%) needed ventilation 24 hours or sooner from sepsis onset. Further, more than a quarter of patients (n = 1,092; 28.1%) were put on mechanical ventilation between 3 to 30 days following sepsis diagnosis.

Compared with adults who did not require mechanical ventilation, those who did demonstrated worse rates of illness severity measured by the Acute Physiology and Chronic Health Evaluation II score at baseline (mean score, 7 vs. 5; P < .001), as well as in-hospital mortality (21% vs. 7%; P < .001).

Following adjustment for confounders, researchers observed several factors that placed patients with sepsis at a heightened risk for mechanical ventilation, with race demonstrating the greatest risk (white, adjusted HR = 1.59; 95% CI, 1.39-1.83; other than Black, Asian or white/unknown, aHR = 1.97; 95% CI, 1.54-2.52).

Other risk factors included systemic inflammatory response syndrome (SIRS) scores (aHR per point = 1.23; 95% CI, 1.17-1.28), Sequential Organ Failure Assessment (SOFA) scores (aHR per point = 1.28; 95% CI, 1.26-1.31), as well as three different comorbidities: cardiac arrhythmias (aHR = 1.54; 95% CI, 1.39-1.71), peripheral vascular disorders (aHR = 1.42; 95% CI, 1.3-1.55) and congestive heart failure (aHR = 1.3; 95% CI, 1.17-1.45).

Notably, although being on mechanical ventilation within the 14 days prior to sepsis initially had a protective effect against mechanical ventilation after sepsis diagnosis (aHR = 0.59; 95% CI, 0.51-0.68), researchers found that the risk for mechanical ventilation went up with each day after sepsis onset (aHR per day = 1.07; 95% CI, 1.05-1.09).

To assess how the time following a sepsis diagnosis changed risk factors of mechanical ventilation, researchers conducted three post hoc logistic regressions.

Within the timespan of 30 days following sepsis onset, several factors raised the odds for mechanical ventilation including septic shock, prolonged stay from admission to sepsis onset, male sex, blood loss anemia, cardiac arrhythmias, chronic pulmonary disease, coagulopathy, congestive heart failure, fluid electrolyte disorders, other neurological disorders, paralysis, peripheral vascular disorders, pulmonary circulation disorders, renal failure, valvular disease and several sepsis laboratory values.

Researchers continued to see male sex, septic shock, cardiac arrhythmias, chronic pulmonary disease, congestive heart failure, fluid electrolyte disorders, other neurological disorders, paralysis, peripheral vascular disorders and several laboratory values as risk factors for mechanical ventilation within 24 hours of sepsis onset after adjusting for confounders. Additional factors linked to heightened odds for ventilation during this time interval included lower SOFA score and higher SIRS score.

Lastly, risk factors for mechanical ventilation between 1 to 30 days following sepsis onset included several comorbidities: blood loss anemia, cardiac arrhythmias, coagulopathy, congestive heart failure, fluid electrolyte disorders, other neurological disorders, peripheral vascular disorders, pulmonary circulation disorders, renal failure and valvular disease. Notably, for this timeframe, researchers did not find heightened odds for mechanical ventilation with male sex, septic shock, SOFA score or SIRS score.

“Using a large, highly granular database of septic patients, we were able to study their progression to respiratory failure,” Freundlich told Healio. “These data will allow providers to better understand when and how to optimally prevent respiratory failure in sepsis.

“While we have provided valuable information about what patients are at elevated risk, it's still unclear how best to treat high-risk patients,” he added. “In this manuscript, we propose a few interventions that we think are worth exploring in future studies, including more careful titration of intravenous fluids, noninvasive ventilation, and heated, humidified high-flow nasal cannula oxygen.”

Reference:

• Analysis reveals factors associated with patients with sepsis who require mechanical ventilation. https://www.newswise.com/articles/analysis-reveals-factors-associated-with-patients-with-sepsis-who-require-mechanical-ventilation. Published Sept. 1, 2023. Accessed Sept. 1, 2023.