Papers by Frederick A Moore
Nutritional Support for Abdominal Sepsis
Hot Topics in Acute Care Surgery and Trauma, Jun 23, 2017
Intra-abdominal sepsis can be a challenging pathophysiologic state. There are a lot of misconcept... more Intra-abdominal sepsis can be a challenging pathophysiologic state. There are a lot of misconceptions surrounding nutrition supplementation in patients with intra-abdominal sepsis. Persistent inflammation immunosuppression catabolism syndrome (PICS) is a new phenotype of multiple organ failure associated with a severe stress such as intra-abdominal sepsis. Nutritional support of these patients is paramount to their recovery and should still largely follow the ASPEN guidelines. Certain nutritional adjuncts could ultimately prove to provide benefit in treating patients with intra-abdominal sepsis and PICS.
Gut Dysfunction in Trauma Patients
Springer eBooks, 1996
With the development of regionalized trauma care, patients who were previously found dead in the ... more With the development of regionalized trauma care, patients who were previously found dead in the field are now surviving to be admitted to regional trauma centers [1]. Early in-hospital deaths occur as a result of severe brain injury and irreversible shock while the leading cause of late deaths is multiple organ failure (MOF). Early risk factors for MOF include high injury severity score (ISS), advanced age, blood transfusions, and persistent shock [2, 3]. While it is difficult to implicate gut dysfunction in early brain death, it has recently been emphasized to be important in the pathogenesis of irreversible hemorrhagic shock and MOF [4-14]. The principle mechanism by which gut dysfunction is presumed to mediate these adverse outcomes is bacterial translocation (BT). In this chapter, we would like to discuss three gut-related questions that specifically differentiate time after injury into resuscitation, the early systemic inflammatory response syndrome (SIRS) and late organ failure.
Nonocclusive mesenteric ischemia: A rare but lethal complication of enteral nutrition in critically ill patients
Nutrition in Clinical Practice, Aug 31, 2021
BackgroundThe American Society for Parenteral and Enteral Nutrition (ASPEN)/ Society of Critical ... more BackgroundThe American Society for Parenteral and Enteral Nutrition (ASPEN)/ Society of Critical Care Medicine and the European Society for Clinical Nutrition and Metabolism guidelines recognize that critically ill patients receiving stable, low doses of vasopressors have experienced the advantages of early initiation of enteral nutrition (EN). However, clinical questions remained unanswered including vasopressor combinations associated with complications, the advent of other therapies during hypotensive states, as well as the volume and content of EN that might contribute to the development of a nonocclusive mesenteric ischemia (NOMI).PresentationA 68‐year old male with a history of hypertension, hyperlipidemia, atrial fibrillation, coronary artery disease with two‐vessel bypass grafting, and peripheral vascular disease underwent subtotal excision of an infected right axillofemoral‐femoral bypass graft. Postoperatively, EN was held because of hemodynamic instability and postsurgical complications. A fiber‐free, high‐protein, and low‐residue formula was started at 10 ml/h while the patient was receiving stable doses of midodrine, norepinephrine, and vasopressin. Despite advancement of tube‐feed rates to goal, nasogastric output never exceeded 300 ml. Computerized tomography of the abdomen showed diffuse bowel distention with pneumatosis, concerning for bowel ischemia. No surgical interventions were pursued, and the patient died.ConclusionsOur patient developed NOMI postoperatively while receiving EN. Further studies addressing EN route, trophic vs full EN, recommended formula, the safety of vasoactive agents, the addition of fiber to EN, and continuous venovenous hemodiafiltration in relation to NOMI are needed, as there continues to be clinical controversy regarding these topics.
Nutrition for Chronic Critical Illness and Persistent Inflammatory, Immunosuppressed, Catabolic Syndrome
Springer eBooks, 2019
The hallmark of chronic critical illness (CCI) and persistent inflammatory, immunosuppressed, cat... more The hallmark of chronic critical illness (CCI) and persistent inflammatory, immunosuppressed, catabolic syndrome (PICS) is the continued breakdown of lean muscle leading to profound weakness, decreased capacity for rehabilitation, immunosuppression, and a propensity to develop recurrent nosocomial infections. Better critical care support systems and advances in technology have led to increased patient survival, but unfortunately, CCI and PICS have emerged as a frequent phenotype among critical care survivors. With an aging population and continued advancements in critical care support systems, the prevalence of CCI and PICS is anticipated to increase. Unfortunately, therapies to mitigate or reverse CCI and PICS are limited. A lack of randomized controlled trials has limited strong recommendations for nutrition support in the CCI patients. Nutritional therapies for PICS may be of biologic value, and this chapter will describe recent advances and draw inferences from the literature to support nutritional interventions in PICS.
Nutritional Support in the Setting of Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS)
Current Surgery Reports, Aug 8, 2016
Purpose of ReviewThe Persistent Inflammation, Immunosuppression, and Catabolism syndrome (PICS) i... more Purpose of ReviewThe Persistent Inflammation, Immunosuppression, and Catabolism syndrome (PICS) is a new phenotype of survivors of critical illness that occurs after major inflammatory insults such as sepsis, severe postoperative complication, and trauma.Recent FindingsThese chronically, critically ill patients suffer from dismal outcomes but little is known about how to prevent or treat this syndrome. Through a recently awarded P50 grant the University of Florida aims to produce translational research to understand the etiology and therapeutic intervention for PICS.SummaryIn creating awareness of nutritional supplementation for PICS, we hope to bring attention and understanding that this unique phenotype cannot be viewed as the ordinary ICU patient. Nutritional support for PICS can be developed using certain supplementations. Through specialized immunonutrition, anabolic nutrition, and inference we can make from Burn, Cachexia, and Sarcopenia, intensivist can start on the path to treating PICS patients. These supplements come in the form of pro-resolving mediators, leucine, and arginine.
Biomarker Evidence of the Persistent Inflammation, Immunosuppression and Catabolism Syndrome (PICS) in Chronic Critical Illness (CCI) after Surgical Sepsis
Annals of Surgery, Jul 14, 2021
Objective: To analyze serial biomarkers of the persistent inflammation, immunosuppression, and ca... more Objective: To analyze serial biomarkers of the persistent inflammation, immunosuppression, and catabolism syndrome (PICS) to gain insight into the pathobiology of chronic critical illness (CCI) after surgical sepsis. Background: Although early deaths after surgical intensive care unit sepsis have decreased and most survivors rapidly recover (RAP), one third develop the adverse clinical trajectory of CCI. However, the underlying pathobiology of its dismal long-term outcomes remains unclear. Methods: PICS biomarkers over 14 days from 124 CCI and 225 RAP sepsis survivors were analyzed to determine associations and prediction models for (1) CCI (≥14 intensive care unit days with organ dysfunction) and (2) dismal 1-year outcomes (Zubrod 4/5 performance scores). Clinical prediction models were created using PIRO variables (predisposition, insult, response, and organ dysfunction). Biomarkers were then added to determine if they strengthened predictions. Results: CCI (vs RAP) and Zubrod 4/5 (vs Zubrod 0–3) cohorts had greater elevations in biomarkers of inflammation (interleukin [IL]-6, IL-8, interferon gamma-induced protein [IP-10], monocyte chemoattractant protein 1), immunosuppression (IL-10, soluble programmed death ligand-1), stress metabolism (C-reactive protein, glucagon-like peptide 1), and angiogenesis (angiopoietin-2, vascular endothelial growth factor, vascular endothelial growth factor receptor-1, stromal cell-derived factor) at most time-points. Clinical models predicted CCI on day 4 (area under the receiver operating characteristics curve [AUC] = 0.89) and 1 year Zubrod 4/5 on day 7 (AUC = 0.80). IL-10 and IP-10 on day 4 minimally improved prediction of CCI (AUC = 0.90). However, IL-10, IL-6, IL-8, monocyte chemoattractant protein 1, IP-10, angiopoietin-2, glucagon-like peptide 1, soluble programmed death ligand-1, and stromal cell-derived factor on day 7 considerably improved the prediction of Zubrod 4/5 status (AUC = 0.88). Conclusions: Persistent elevations of PICS biomarkers in the CCI and Zubrod 4/5 cohorts and their improved prediction of Zubrod 4/5 validate that PICS plays a role in CCI pathobiology.
Older Adults Demonstrate Biomarker Evidence of the Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS) After Sepsis
The Journals of Gerontology, Mar 15, 2021
Background Hospital deaths after sepsis have decreased substantially and most young adult survivo... more Background Hospital deaths after sepsis have decreased substantially and most young adult survivors rapidly recover (RAP). However, many older survivors develop chronic critical illness (CCI) with poor long-term outcomes. The etiology of CCI is multifactorial and the relative importance remains unclear. Sepsis is caused by a dysregulated immune response and biomarkers reflecting a persistent inflammation, immunosuppression, and catabolism syndrome (PICS) have been observed in CCI after sepsis. Therefore, the purpose of this study was to compare serial PICS biomarkers in (i) older (vs young) adults and (ii) older CCI (vs older RAP) patients to gain insight into underlying pathobiology of CCI in older adults. Method Prospective longitudinal study with young (≤45 years) and older (≥65 years) septic adults, who were characterized by (i) baseline predisposition, (ii) hospital outcomes, (iii) serial Sequential Organ Failure Assessment (SOFA) organ dysfunction scores over 14 days, (iv) Zubrod Performance status at 3-, 6-, and 12-month follow-up, and (v) mortality over 12 months, was conducted. Serial blood samples over 14 days were analyzed for selected biomarkers reflecting PICS. Results Compared to the young, more older adults developed CCI (20% vs 42%) and had markedly worse serial SOFA scores, performance status, and mortality over 12 months. Additionally, older (vs young) and older CCI (vs older RAP) patients had more persistent aberrations in biomarkers reflecting inflammation, immunosuppression, stress metabolism, lack of anabolism, and antiangiogenesis over 14 days after sepsis. Conclusion Older (vs young) and older CCI (vs older RAP) patient subgroups demonstrate early biomarker evidence of the underlying pathobiology of PICS.
Persistent inflammation and anemia among critically ill septic patients
The journal of trauma and acute care surgery, Feb 1, 2019
BACKGROUND Associations among inflammatory cytokines, erythropoietin (EPO), and anemia in critica... more BACKGROUND Associations among inflammatory cytokines, erythropoietin (EPO), and anemia in critically ill septic patients remain unclear. This study tested the hypothesis that elevated inflammatory cytokines and decreased EPO would be associated with iron-restricted anemia while accounting for operative blood loss, phlebotomy blood loss, and red blood cell (RBC) transfusion volume. METHODS Prospective observational cohort study of 42 critically ill septic patients was conducted. Hemoglobin (Hb) at sepsis onset and hospital discharge were used to calculate ΔHb. Operative blood loss, phlebotomy blood loss, and RBC transfusion volume were used to calculate adjusted ΔHb (AdjΔHb) assuming that 300 mL RBC is equal to 1 g/dL Hb. Patients with AdjΔHb of greater than 0 (positive AdjΔHb, n = 18) were compared with patients with AdjΔHb of less than or equal to 0 (negative AdjΔHb, n = 24). RESULTS Plasma tumor necrosis factor α, granulocyte colony-stimulating factor, interleukin (IL)-6, IL-8, EPO, erythrocyte mean corpuscular volume, and serum transferrin receptor were measured on days 0, 1, 4, 7, and 14. Patients with negative AdjΔHb had significantly higher day 14 levels of IL-6 (37.4 vs. 15.2 pg/mL, p < 0.05), IL-8 (39.1 vs. 18.2 pg/mL, p = 0.01), and granulocyte colony-stimulating factor (101.3 vs. 60.5 pg/mL, p = 0.01), but not EPO. On linear regression analysis, lower AdjΔHb was associated with higher day 14 levels of IL-6 (r 2 = 0.22, p < 0.01), IL-8 (r 2 = 0.10, p = 0.04), stromal cell–derived factor 1 (r 2 = 0.14, p = 0.02), and tumor necrosis factor α (r 2 = 0.13, p = 0.02), but not EPO. Patients with negative AdjΔHb had significantly lower mean corpuscular volume on days 4 (89.6 vs. 93.2 fL/cell, p = 0.04), 7 (92.3 vs. 94.9 fL/cell, p = 0.04), and 14 (92.1 vs. 96.0 fL/cell, p = 0.03) but similar serum transferrin receptor levels. CONCLUSION Persistent elevation of inflammatory cytokines was associated with iron-restricted anemia among critically ill septic patients, occurring in the absence of systemic iron deficiency, independent of endogenous EPO. LEVEL OF EVIDENCE Prognostic study, level II.
Critical Care, May 7, 2020
Background The role of site of infection in sepsis has been poorly characterized. Additionally, s... more Background The role of site of infection in sepsis has been poorly characterized. Additionally, sepsis epidemiology has evolved. Early mortality has decreased, but many survivors now progress into chronic critical illness (CCI). This study sought to determine if there were significant differences in the host response and current epidemiology of surgical sepsis categorized by site of infection. Study design This is a longitudinal study of surgical sepsis patients characterized by baseline predisposition, insult characteristics, serial biomarkers, hospital outcomes, and long-term outcomes. Patients were categorized into five anatomic sites of infection. Results The 316 study patients were predominantly Caucasian; half were male, with a mean age of 62 years, high comorbidity burden, and low 30-day mortality (10%). The primary sites were abdominal (44%), pulmonary (19%), skin/soft tissue (S/ST, 17%), genitourinary (GU, 12%), and vascular (7%). Most abdominal infections were present on a...
The impact of sarcopenia and acute muscle mass loss on long‐term outcomes in critically ill patients with intra‐abdominal sepsis
Journal of Cachexia, Sarcopenia and Muscle, Jun 30, 2021
BackgroundSarcopenia is a known risk factor for poor outcomes across many chronic diseases. The i... more BackgroundSarcopenia is a known risk factor for poor outcomes across many chronic diseases. The impact on outcomes of both pre‐existing sarcopenia and acute muscle wasting (AMW) in acute critical illness caused by sepsis remain unclear.MethodsWe conducted a prospective longitudinal cohort study of critically ill patients with intra‐abdominal sepsis utilizing abdominal computed tomography at sepsis onset to determine baseline skeletal muscle index (SMI). Biomarkers of inflammation and catabolism were measured through 28 days while hospitalized. We performed follow‐up evaluations of strength and physical function at 3, 6, and 12 months, with interval CT analyses at 3 and 12 months to evaluate changes in muscle mass. Measured clinical outcomes included development of chronic critical illness (≥14 days in intensive care with persistent organ dysfunction), long‐term functional status, and 1 year mortality.ResultsAmong 47 sepsis patients enrolled (mean age 53 ± 14 years), half (n = 23; 49%) were sarcopenic at baseline. Overall, sepsis patients exhibited acute and persistent muscle wasting with an average 8% decrease in SMI from baseline at 3 months (P = 0.0008). Sarcopenic (SAR) and non‐sarcopenic (NSAR) groups were similar in regards to age and comorbidity burden. SAR patients had greater acute physiologic derangement (APACHE II, 18 vs. 12.5), higher incidence of multiple organ failure (57% vs. 17%), longer hospital (21 vs. 12 days) and intensive care unit length of stays (13 vs. 4 days), and higher inpatient mortality (17% vs. 0%; all P < 0.05). Pre‐existing SAR was a strong independent predictor of early death or developing chronic critical illness (odds ratio 11.87, 95% confidence interval CI 1.88–74.9; P = 0.009, area under the curve 0.880) and was associated with significantly higher risk of 1‐year mortality (34.9% vs. 4.2%, p = 0.007). Lower baseline SMI was also predictive of poor functional status at 12 months (OR 0.89, 95% confidence interval 0.80–0.99; p = 0.039, area under the curve 0.867). Additionally, SAR patients had AMW with persistent muscle mass loss at 3 months that was associated with decreased health‐related quality of life and SF‐36 physical function domains (P < 0.05). Persistent AMW at 3 months was not predictive of mortality or poor functional status, with return to near‐baseline muscle mass among sepsis survivors by 6 months.ConclusionsCritically ill patients have an acute and persistent loss of muscle mass after intra‐abdominal sepsis, which is associated with decreased health‐related quality of life and physical function at 3 months. However, pre‐existing sarcopenia, rather than persistent acute muscle mass loss at 3 months after sepsis, is independently associated with poor long‐term functional status and increased 1 year mortality.
Older Sepsis Survivors Suffer Persistent Disability Burden and Poor Long‐Term Survival
Journal of the American Geriatrics Society, Apr 15, 2020
ObjectivesSepsis has been called a “disease of the elderly,” and as in‐hospital mortality has dec... more ObjectivesSepsis has been called a “disease of the elderly,” and as in‐hospital mortality has decreased, more sepsis survivors are progressing into poorly characterized long‐term outcomes. The purpose of this study was to describe the current epidemiology of sepsis in older adults compared with middle‐aged and young adults.DesignProspective longitudinal study with young (≤45 years), middle‐aged (46‐64 years), and older (≥65 years) patient groups.SettingUniversity tertiary medical center.ParticipantsA total of 328 adult surgical intensive care unit (ICU) sepsis patients.MeasurementsPatients were characterized by (1) baseline demographics and predisposition, (2) septic event, (3) hospital outcomes and discharge disposition, (4) 12‐month mortality, and (5) Zubrod Performance Status, physical function (Short Physical Performance Battery and handgrip strength), and cognitive function (Hopkins Verbal Learning Test, Controlled Oral Word Association, and Mini‐Mental Status Examination) at 3‐, 6‐, and 12‐month follow‐up. Loss to follow‐up was due to death (in 68), consent withdrawal (in 32), and illness and scheduling difficulties: month 3 (in 51), month 6 (in 29), and month 12 (in 20).ResultsCompared with young and middle‐aged patients, older patients had (1) significantly more comorbidities at presentation (eg, chronic renal disease 6% vs 12% vs 21%), intra‐abdominal infections (14% vs 25% vs 37%), septic shock (12% vs 25% vs 36%), and organ dysfunctions; (2) higher 30‐day mortality (6% vs 4% vs 17%) and fewer ICU‐free days (median = 25 vs 23 vs 20); (3) more progression into chronic critical illness (22% vs 34% vs 42%) with higher poor disposition discharge to non‐home destinations (19% vs 40% vs 62%); (4) worse 12‐month mortality (11% vs 14% vs 33%); and (5) poorer Zubrod Performance Status and objectively measured physical and cognitive functions with only slight improvement over 12‐month follow‐up.ConclusionCompared with younger patients, older sepsis survivors suffer both a higher persistent disability burden and 12‐month mortality.
Early Diagnosis and Evidence-Based Care of Surgical Sepsis
Journal of Intensive Care Medicine, Jul 11, 2011
Sepsis continues to be a common and serious problem among surgical patients. It is a leading caus... more Sepsis continues to be a common and serious problem among surgical patients. It is a leading cause of both morbidity and mortality in the perioperative period. The early identification of sepsis and the early implementation of evidence-based care can improve outcomes. This focused review will identify ways to improve the early identification of sepsis and discuss the current evidence-based guidelines for the early management of sepsis, severe sepsis, and septic shock in the surgical patients.
Surgical Clinics of North America, Dec 1, 2012
Surgical patients account for nearly one-third of sepsis cases in the United States. Sepsis remai... more Surgical patients account for nearly one-third of sepsis cases in the United States. Sepsis remains the leading cause of death in noncardiac intensive care units. Early identification of patients and timely implementation of evidence-based therapies continue to represent significant clinical challenges for care providers. The implementation of a sepsis screening program in conjunction with protocol for the delivery of evidence-based care and rapid source control can improve patient outcomes.
Current Epidemiology of Surgical Sepsis
Annals of Surgery, Sep 1, 2019
Objective: We sought to compare traditional inpatient outcomes to long-term functional outcomes a... more Objective: We sought to compare traditional inpatient outcomes to long-term functional outcomes and mortality of surgical intensive care unit (SICU) patients with sepsis. Summary of Background Data: As inpatient sepsis mortality declines, an increasing number of initial sepsis survivors now progress into a state of chronic critical illness (CCI) and their post-discharge outcomes are unclear. Methods: We performed a prospective, longitudinal cohort study of SICU patients with sepsis. Results: Among this recent cohort of 301 septic SICU patients, 30-day mortality was 9.6%. Only 13 (4%) patients died within 14 days, primarily of refractory multiple organ failure (62%). The majority (n = 189, 63%) exhibited a rapid recovery (RAP), whereas 99 (33%) developed CCI. CCI patients were older, with greater comorbidities, and more severe and persistent organ dysfunction than RAP patients (all P < 0.01). At 12 months, overall cohort performance status was persistently worse than presepsis baseline (WHO/Zubrod score 1.4 ± 0.08 vs 2.2 ± 0.23, P > 0.0001) and mortality was 20.9%. Of note at 12 months, the CCI cohort had persistent severely impaired performance status and a much higher mortality (41.4%) than those with RAP (4.8%) after controlling for age and comorbidity burden (Cox hazard ratio 1.27; 95% confidence interval, 1.14–1.41, P < 0.0001). Among CCI patients, independent risk factors for death by 12 months included severity of comorbidities and persistent organ dysfunction (sequential organ failure assessment ≥6) at day 14 after sepsis onset. Conclusions: There is discordance between low inpatient mortality and poor long-term outcomes after surgical sepsis, especially among older adults, increasing comorbidity burden and patients that develop CCI. This represents important information when discussing expected outcomes of surgical patients who experience a complicated clinical course owing to sepsis.
Surgery, Aug 1, 2018
As early as the 1990's, chronic critical illness (CCI), a distinct syndrome of persistent high-ac... more As early as the 1990's, chronic critical illness (CCI), a distinct syndrome of persistent high-acuity illness requiring management in the intensive care unit (ICU), was reported under a variety of descriptive terms including the "neuropathy of critical illness," "myopathy of critical illness," "ICU acquired weakness," and most recently "post intensive care unit syndrome". The widespread implementation of targeted shock resuscitation, improved organ support modalities, and evidencebased protocolized ICU care has resulted in significantly decreased in-hospital mortality within surgical ICUs (SICU), specifically by reducing early multiple organ failure (MOF) deaths. However, a new phenotype of MOF has now emerged with persistent, but manageable organ dysfunction, high resource utilization, and discharge to prolonged care facilities. This new MOF phenotype is now clinically associated with the rapidly increasing incidence of CCI in critically ill surgery patients. While the underlying pathophysiology driving CCI remains incompletely described, the Persistent, Inflammation, Immunosuppression and Catabolism syndrome (PICS) has been proposed as a mechanistic framework in which to explain the increased incidence of CCI in SICUs. The purpose of this review is to provide a historic perspective of the epidemiologic
Medicine, Dec 1, 2015
Determine what clinical role, if any, GM-CSF may have in Although sepsis is known to cause severe... more Determine what clinical role, if any, GM-CSF may have in Although sepsis is known to cause severe alterations in both adaptive and innate immunity, the clinical model
Archives of Surgery, Jul 1, 2010
To document the incidence, mortality rate, and risk factors for sepsis and septic shock compared ... more To document the incidence, mortality rate, and risk factors for sepsis and septic shock compared with pulmonary embolism and myocardial infarction in the general-surgery population.
Gut Bacterial Translocation via the Portal Vein
Journal of Trauma-injury Infection and Critical Care, May 1, 1991
ABSTRACT Animal studies implicate gut bacterial translocation via the portal vein as a major fact... more ABSTRACT Animal studies implicate gut bacterial translocation via the portal vein as a major factor in the pathogenesis of postinjury multiple organ failure (MOF). We therefore inserted portal vein catheters for sequential blood sampling in the operating room, at 6, 12, 24, and 48 hours, and 5 days postoperatively in 20 injured patients (13 blunt, seven penetrating; mean age, 34 years) requiring emergent laparotomy and who were at known risk for MOF. The mean Revised Trauma Score was 6.4 +/- 0.4, and the Injury Severity Score, 29.3 +/- 2.3. Twelve (60%) patients arrived in shock (SBP < 90 torr). Eight (2%) of 212 portal blood cultures were positive; seven were presumed contaminants. The only positive systemic culture (total, 212) was a Staphylococcus aureus on day 5 in a patient with a concurrent staphyloccal pneumonia. In the first 48 hours, we could not detect endotoxin in portal or systemic blood. Additionally, simultaneous portal and systemic blood levels of complement fragment C3a, tumor necrosis factor, and interleukin-6 were nearly identical and, specifically, were not different in those patients who developed MOF. In summary, this prospective clinical study has not confirmed portal or systemic bacteremia within the first 5 days postinjury, despite an eventual 30% incidence of MOF.
The long-term burden of severe sepsis and septic shock
The journal of trauma and acute care surgery, Sep 1, 2016
Severe sepsis and septic shock mortality has improved, however rates of persistent (28 to 90 day)... more Severe sepsis and septic shock mortality has improved, however rates of persistent (28 to 90 day) and long-term (>90 day) organ dysfunction in sepsis survivors are unknown. Secondary analysis of a prospective cohort of adult Emergency Department patients with severe sepsis. Of 110 sepsis admissions, we obtained follow up on 51 of 78 survivors of whom 41% (21/51) had persistent organ dysfunction: pulmonary 18% (9/51), renal 22% (11/51), coagulopathy 10% (5/51), cardiovascular 6% (3/51), hepatic 2% (1/51), and neurologic 3% (3/51). We obtained follow up on 40 of 73 survivors at >90 days of whom 38% (15/40) had long-term organ dysfunction: pulmonary 13% (5/40), renal 18% (7/40), coagulopathy 3% (1/40), cardiovascular 5% (2/40), hepatic 0%, and neurologic 5% (2/40). Readmission rate within 90 days was 32% (25/78) and recurrent sepsis was the cause of readmission in 52% (13/25). Baseline SOFA scores from the index sepsis admission were compared using Wilcoxon's rank-sum test and were significantly different in participants with vs without organ dysfunction at <90 days. (z = -2.51, p = 0.01). Readmission with recurrent sepsis and organ dysfunction occurs frequently in sepsis survivors. Baseline SOFA score may be predictive of sepsis recidivism and persistent or recurrent organ dysfunction. IV STUDY TYPE: Prognostic Study.
Chronic Critical Illness Patients Fail to Respond to Current Evidence‐Based Intensive Care Nutrition Secondarily to Persistent Inflammation, Immunosuppression, and Catabolic Syndrome
Journal of Parenteral and Enteral Nutrition, Feb 6, 2020
BackgroundSepsis‐induced multiple‐organ failure (MOF) has plagued surgical intensive care units (... more BackgroundSepsis‐induced multiple‐organ failure (MOF) has plagued surgical intensive care units (ICUs) for decades. Early nutrition (principally enteral) improves hospital outcomes of high‐risk ICU patients. The purpose of this study is to document how the growing epidemic of chronic critical illness (CCI) patients responds to adequate evidence‐based ICU nutrition.MethodsThis retrospective post hoc subgroup analysis of an ongoing sepsis database identified 56 CCI patients who received early, adequate nutrition per an established surgical ICU protocol compared with 112 matched rapid‐recovery (RAP) patients.ResultsThe matched CCI and RAP groups had similar baseline characteristics. Serial biomarkers showed that CCI patients remained persistently inflamed with ongoing stress metabolism and that despite receiving evidence‐based protocol nutrition, they had persistent catabolism and immunosuppression with more secondary infections. More CCI patients were discharged to poor nonhome destinations (ie, skilled nursing facilities, long‐term acute care, hospice) (81% vs 29%, P < 0.05). At 12‐month follow‐up, CCI patients had worse functional status by Zubrod score (3.17 vs 1.62, P < 0.001) and Short Physical Battery Testing (4.78 vs 8.59, P < 0.02), worse health‐related quality of life by EQ‐5D‐3L descriptive measures (9.07 vs 7.45, P < 0.003), and lower survival (67% vs 92%, P < 0.05).ConclusionsDespite early, adequate, evidence‐based ICU nutrition, septic surgical ICU patients who develop CCI exhibit persistent inflammation, immunosuppression, and catabolism with unacceptable long‐term morbidity and mortality. Although current evidence‐based ICU nutrition may improve short‐term ICU outcomes, novel adjuncts are needed to improve long‐term outcomes for CCI patients.
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Papers by Frederick A Moore