Summary
In 47 medical and postoperative ICU patients with 57 episodes of sepsis and septic shock, cardiovascular parameters including systemic vascular resistance (SVR), cardiac index (CI), stroke volume index (SVI), left ventricular stroke work index (LVSWI) as well as six scoring systems (APACHE II, Elebute, Goris, HIS, SAPS and SSS) were studied regarding their usefulness in the assessment of disease progression and evaluation of response to supplemental sepsis therapy (immunoglobulins, plasmapheresis). Among the hemodynamic parameters, only a prompt SVR improvement significantly discriminated between ultimate survivors and nonsurvivors. Thus, an increase in SVR (>160 dyn*cm−5*sec, within days 0 to 4, persisting for >24 hours) can serve as a prognostically validated “response” criterion (responders/non-responders: 26/31; mortality: 27% vs. 77%). Non-invasively, the APACHE II score was best suited (specificity: 88%, sensitivity: 67%) to classify hemodynamically defined responders to supplemental sepsis treatment (score-reduction ≥4 on day 4 after onset of therapy).
Zusammenfassung
Bei 47 internistischen sowie postoperativen Intensivpatienten mit insgesamt 57 Episoden von Sepsis und septischem Schock wurden Herz-Kreislauf-Parameter inklusive systemischer Gefäßwiderstand (SGW), Herzindex, Schlagvolumenindex und linksventrikulärer Schlagarbeitsindex sowie sechs Score-Systeme (APACHE II, Elebute, Goris, HIS, SAPS und SSS) in ihrer Wertigkeit zur Beurteilung des Krankheitsverlaufes sowie des Ansprechens auf additive Sepsistherapie (Immunglobuline, Plasmapherese) untersucht. Von den hämodynamischen Parametern diskriminierte nur der — prompt nachweisbare — Anstieg des SGW signifikant zwischen letztlich überlebenden und nicht überlebenden Patienten. Ein Anstieg des SGW (>160 dyn*cm−5*s innerhalb von vier Tagen, länger als 24 Stunden anhaltend) kann somit als prognostisch validiertes „Responder“-Kriterium dienen (Responder/Non-Responder: 26/31; Letalität: 27% vs. 77%). Nichtinvasiv erwies sich der APACHE II Score (Kriterium: Score-Abfall ≥4 bis zum Tag 4 nach Therapiebeginn) zur Klassifizierung der hämodynamisch definierten Therapie-„Responder“ bei additiver Sepsistherapie am besten geeignet (Spezifität: 88%, Sensitivität 67%).
Similar content being viewed by others
References
Dellinger, E. P. Use of scoring systems to assess patients with surgical sepsis. Surg. Clin. North America 68 (1988) 123–145.
Fink, P. C., Erdmann, R., Schöndube, F., Baca, I. Leucocytes, neutrophilia and elastase-α1-proteinase-inhibitor-complex: marker of different validity for monitoring the perioperative infection risk. In:Schlag, G., Redl, H. (eds.): Progress in clinical and biological research, Second Vienna Shock Forum, Vol. 308. Alan R. Liss, New York 1989, pp. 695–700.
Pilz, G., Stäblein, A., Reuschel-Janetschek, E., Autenrieth, G., Werdan, K. The use of scoring systems in patients with cardiogenic and septic shock. In:Schlag, G., Redl, H. (eds.). Progress in clinical and biological research, Second Vienna Shock Forum, Vol. 308. Alan R. Liss, New York 1989, pp. 625–631.
Kipping, N., Grundmann, R., Hornung, M., Wesoly, C. Efficiency of sepsis score, AT III- and endotoxin evaluation in predicting the prognosis of postoperative sepsis in the intensive care unit. In:Schlag, G., Redl, H. (eds.). Progress in clinical and biological research, Second Vienna Shock Forum, Vol. 308. Alan R. Liss, New York 1989, pp. 637–642.
Dominioni, L., Dionigi, R., Zanello, M., Monico, R., Cremaschi, R., Dionigi, R., Ballabio, A., Massa, M., Comelli, M., Dal Ri, P., Pisati, P. Sepsis score and acute-phase protein response as predictors of outcome in septic surgical patients. Arch. Surg. 122 (1987) 141–146.
Redl, G., Zadrobilek, E., Schindler, I., Mauritz, W., Sporn, P. Judgement of central haemodynamics with and without Swan Ganz catheter in septic shock states. In:Schlag, G., Redl, H. (eds.). Progress in clinical and biological research, First Vienna Shock Forum, Vol. 236-B Monitoring and treatment of shock. Alan R. Liss, New York 1987, pp. 123–128.
Knaus, W. A., Wagner, D. P., Draper, E. A. The value of measuring severity of disease in clinical research on acutely ill patients. J. Chron. Dis. 37 (1984) 455–463.
Wilson, R. F., Thal, A. P., Kindling, P. H., Grifka, T., Ackerman, E. Hemodynamic measurements in septic shock. Arch. Surg. 91 (1965) 121–129.
Winslow, E. J., Loeb, H. S., Rahimtoola, S. H., Kamath, S., Gunnar, R. M. Hemodynamic studies and results of therapy in 50 patients with bacteremic shock. Am. J. Med. 54 (1973) 421–432.
Parker, M. M., Parillo, J. E. Septic shock: hemodynamics and pathogenesis. JAMA 250 (1983) 3324–3327.
Parker, M. M., Shelhamer, J. H., Bacharach, S. L., Green, M. V., Natanson, C., Frederick, T. M., Damske, B. A., Parillo, J. E. Profound but reversible myocardial depression in patients with septic shock. Ann. Int. Med. 100 (1984) 483–490.
Abraham, E., Bland, R. D., Cobo, J. C., Shoemaker, W. C.: Sequential cardiorespiratory patterns associated with outcome in septic shock. Chest (1984) 75–80.
Baumgartner, J. D., Vaney, E., Perret, C. An extreme form of the hyperdynamic syndrome in septic shock. Intensive Care Med. 10 (1984) 245–249.
Parker, M. M., Shelhamer, J. H., Natanson, C., Alling, D. W., Parillo, J. E. Serial cardiovascular variables in survivors and nonsurvivors of human septic shock: heart rate as an early predictor of prognosis. Crit. Care Med. 15 (1987) 923–929.
Groeneveld, A. B. J., Bronsveld, W., Thijs, L. G. Hemodynamic determinants of mortality in human septic shock. Surgery 99 (1986) 140–152.
Artucio, H., Digenio, A., Pereyra, M. Left ventricular function during sepsis. Crit. Care Med. 17 (1989) 323–327.
Lenz, K., Laggner, A., Druml, W., Graninger, G., Grimm, G., Schneeweiß, B. Hemodynamic characterization of sepsis. In:Schlag, G., Redl, H. (eds.): Progress in clinical and biological research, First Vienna Shock Forum, Vol. 236-B Monitoring and treatment of shock. Alan R. Liss, New York 1987, pp. 129–138.
Tuchschmidt, J., Fried, J., Swinney, R., Sharma, O. P. Early hemodynamic correlates of survival in patients with septic shock. Crit. Care Med. 17 (1989) 719–723.
Goris, R. J. A., Boekhorst, T. P. A.:Nuytinck, J. K. S., Gimbrere, J. S. F. Multiple organ failure: generalized autodestructive inflammation? Arch. Surg. 120 (1985) 1109–1115.
Cerra, F. B. The systemic septic response: Multiple systems organ failure. Crit. Care Clin. 1 (1985) 591–607.
Elebute, E. A., Stoner, H. B. The grading of sepsis. Br. J. Surg. 70 (1983) 29–31.
Stevens, L. E. Gauging the severity of surgical sepsis. Arch. Surg. 118 (1983) 1190–1192.
Knaus, W. A., Draper, E. A., Wagner, D. P., Zimmerman, J. E. APACHE II: A severity of disease classification system. Crit. Care Med. 13 (1985) 818–829.
Lehmkuhl, P., Jeck-Thole, S., Pichlmayr, I. A new scoring system for disease intensity in a surgical intensive care unit. World J. Surg. 13 (1989) 252–258.
Le Gall, J. R., Loirat, P., Alperovitch, A., Glaser, P., Granthill, C., Mathieu, D., Mercier, P., Thomas, R., Villers, D. A simplified acute physiology score for ICU patients. Crit. Care Med. 12 (1984) 975–977.
Bone, R. C., Fisher, C. J., Clemmer, T. P., Slotman, G. J., Metz, C. A., Balk, R. A., andThe Methylprednisolone Severe Sepsis Study Group A controlled clinical trial of high-dose methylprednisolone in the treatment of severe sepsis and septic shock. N. Engl. J. Med. 317 (1987) 653–658.
Hinshaw, L., Peduzzi, P., Young, E., Sprung, C., Shatney, C., Sheagren, J., Wilson, M., Haakenson, C., andThe Veterans Administration Systemic Sepsis Cooperative Study Group Effect of high-dose glucocorticoid therapy on mortality in patients with clinical signs of sepsis. N. Engl. J. Med. 317 (1987) 659–665.
DeMaria, A., Heffernan, J. J., Grindlinger, G. A., Craven, D. E., McIntosh, T. K., McCabe, W. R. Naloxone versus placebo in treatment of septic shock. Lancet i (1985) 1363–1365.
Just, H.-M., Metzger, M., Vogel, W., Pelka, R. B. Therapeutic effects of immunoglobulin in intensive care patients with severe infections. Klin. Wochenschr. 64 (1986) 245–256.
Haque, K. N., Zaidi, M. H., Haque, S. K., Bahakim, H., El-Hazmi, M., El-Swailam, M. Intravenous immunoglobulin for prevention of sepsis in preterm and low birth weight infants. Pediatr. Infect. Dis. 5 (1986) 622–625.
Sidiropoulos, D., Boehme, U., von Muralt, G., Morell, A., Barandun, S. Immunoglobulin supplementation in prevention or treatment of neonatal sepsis. Pediatr. Infect. Dis. 5 (1986) 193–194.
Class, I., Junginger, W., Klöss, T. Pseudomonas immune globulin in surgical intensive care patients on mechanical ventilation. Infection 15 (1987) Suppl. 2, S76-S70.
Fomsgaard, A., Baek, L., Fomsgaard, J. S., Engquist, A. Preliminary study on treatment of septic shock patients with antilipopolysaccharide IgG from blood donors. Scand. J. Infect. Dis. 21 (1989) 697–708.
Ziegler, E. J., McCutchan, J. A., Fierer, J., Glauser, M. P., Sadoff, J. C., Douglas, H., Braude, A. I. Treatment of gram-negative bacteremia and shock with human antiserum to a mutantEscherichia coli. N. Engl. J. Med. 307 (1982) 1225–1230.
Baumgartner, J.-D., McCutchan, J. A., van Melle, G., Vogt, M., Luethy, R., Glauser, M. P., Ziegler, E. J., Klauber, M. R., Muehlen, E., Chiolero, R., Geroulanos, S. Prevention of gram-negative shock and death in surgical patients by antibody to endotoxin core glycolipid. Lancet ii (1985) 60–63.
Werdan, K., Bauriedel, G., Samtleben, W., Banthien, F. C. A., Haberl, R., Hacker, H., Roth, P., Schultheiß, H. P., Gurland, H. J., Autenrieth, G. Beeinflussung des septischen Schocks durch Plasmapherese. In:Deutsch, E., Druml, W., Kleinberger, G., Ritz, R., Schuster, H. P. (eds.): Akutes Nierenversagen und extrakorporale Therapieverfahren. Aktuelle Intensivmedizin 3. Schattauer, Stuttgart 1986, pp. 429–437.
Bjertnaes, L. J. Plasma exchange in septic shock. In:Schlag, G., Redl, H. (eds.): Progress in clinical and biological research, First Vienna Shock Forum, Vol. 236-B Monitoring and treatment of shock. Alan R. Liss, New York 1987, pp. 215–223.
Montgomery, A. B., Stager, M. A., Carrico, C. J., Hudson, L. D. Causes of mortality in patients with the adult respiratory distress syndrome. Am. Rev. Respir. Dis. 132 (1985) 485–489.
Swan, H. J. C., Ganz, W., Forrester, J., Marcus, H., Diamond, G., Chonette, D. Catherization of the heart in man with use of a flow directed balloon-tipped catheter. N. Engl. J. Med. 283 (1970) 447–451.
Suffredini, A. F., Fromm, R. E., Parker, M. M., Brenner, M., Kovacs, J. A., Wesley, R. A., Parrillo, J. E. The cardiovascular response of normal humans to the administration of endotoxin. N. Engl. J. Med. 321 (1989) 280–287.
Teasdale, G., Jennett, B. Assessment of coma and impaired consciousness: A practical scale. Lancet ii (1974) 81–84.
Jacobs, S., Chang, R. W. S., Lee, B. One year's experience with the Apache II severity of disease classification system in a general intensive care unit. Anaesthesia 42 (1987) 738–744.
Youden, W. J. Index for rating diagnostic tests. Cancer 3 (1950) 32–35.
Hanley, J. A., McNeil, B. J. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 143 (1982) 29–36.
Quale, J. M., Mandel, L. J., Bergasa, N. V., Straus, E. W. Clinical significance and pathogenesis of hyperbilirubinemia associated withStaphylococcus aureus septicemia. Am. J. Med. 85 (1988) 615–618.
Bohnen, M. A., Mustard, R. A., Oxholm, S. E., Schouten, D. APACHE II score and abdominal sepsis. Arch. Surg. 123 (1988) 225–229.
Moreau, R., Soupison, T., Vauquelin, P., Derrida, S., Beaucour, H., Sicot, C. Comparison of two simplified severity scores (SAPS and APACHE II) for patients with acute myocardial infarction. Crit. Care Med. 17 (1989) 409–413.
Jacobs, S., Chang, R. W. S., Lee, B., Lee, B. Audit of intensive care: a 30-month experience using the Apache II severity of disease classification system. Intens. Care Med. 14 (1988) 567–574.
Moser, K. H., Bouillon, B., Troidl, H., Köppen, L. Validation of Continuous APACHE Score (CAPS) for a better prediction of outcome in surgical ICU patients. Theor. Surg. 3 (1989) 192–197.
Hopefl, A. W., Taaffe, C. L., Herrmann, V. M. Failure of APACHE II alone as a predictor of mortality in patients receiving total parenteral nutrition. Crit. Care Med. 17 (1989) 414–417.
Larvin, M., McMahon, M. J. APACHE-II score for assessment and monitoring of acute pancreatitis. Lancet ii (1989) 201–205.
Giangiuliani, G., Mancini, M., Gui, D. Validation of a severity of illness score (APACHE II) in a surgical intensive care unit. Intens. Care Med. 15 (1989) 519–522.
Machin, D., Campbell, M. J. Statistical tables for the design of clinical trials. Blackwell Sc. Publ., Oxford 1987.
Pilz, G., Gurniak, T., Bujdoso, O., Werdan, K.: A basic program for calculation of APACHE II and Elebute scores and sepsis evaluation in intensive care medicine. Comput. Biol. Med., submitted for publication.
Calandra, T., Glauser, M., Schellekens, J., Verhoef, J., andthe Swiss-Dutch J5 Immunoglobulin Study Group Treatment of gramnegative septic shock with human IgG antibody toEscherichia coli J5: a prospective, double blind, randomized trial. J. Infect. Dis. 158 (1988) 312–319.
Werdan, K., Pilz, G., Kääb, S. Haemodynamic effects during treatment of sepsis and septic shock with immunoglobulins and plasmapheresis. In:Schlag, G., Redl, H. (eds.). Progress in clinical and biological research, Second Vienna Shock Forum, Vol. 308. Alan R. Liss, New York 1989, pp. 1025–1030.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Pilz, G., Werdan, K. Cardiovascular parameters and scoring systems in the evaluation of response to therapy in sepsis and septic shock. Infection 18, 253–262 (1990). https://doi.org/10.1007/BF01646996
Issue Date:
DOI: https://doi.org/10.1007/BF01646996