Published online Jul 9, 2022. doi: 10.5492/wjccm.v11.i4.246
Peer-review started: November 6, 2021
First decision: January 12, 2022
Revised: January 17, 2022
Accepted: June 24, 2022
Article in press: June 24, 2022
Published online: July 9, 2022
Processing time: 242 Days and 17.4 Hours
The Sepsis 3.0 criteria for sepsis and septic shock have been extensively used in the definition of severe patients, admitted to hospital care and intensive care, in order to adequately define a subset of patients with poor prognosis and higher mortality rates.
Since its publication in 2016, its use has been presented as a good diagnostic tool to define these patients and to promptly initiate organic support. Coronavirus disease 2019 (COVID-19) patients present a strong association with life-threatening organ dysfunction due to septic shock and frequently require intensive care unit (ICU) admission and organ support.
COVID-19 patients frequently lack hyperlactatemia, a necessary clinical criteria to define septic shock using the Septic Shock 3.0 criteria. Therefore, this could potentially lead to an unrecognized subset of these patients who have a high illness severity and mortality risk, and are inaccurately classified as having sepsis.
This study aimed to identify the proportion of patients with severe COVID-19 with vasopressor requirements without hyperlactatemia and describe their clinical outcomes and mortality rate.
A single-center prospective observational cohort study was conducted in a tertiary hospital in Portugal, analyzing adult patients, admitted to the ICU, with COVID-19 pneumonia. Data collection was extensive, providing data on comorbidities, clinical status, severity indices, respiratory, hemodynamic, and renal dysfunction and the outcome of these COVID-19 patients.
Twenty-two percent of the analyzed COVID-19 patients were found to have persistent hypotension despite adequate volume resuscitation, requiring vasopressor support, and without hyperlactatemia. This "Vasoplegic Shock" group was found to have high 28-day and hospital mortality rates, and few vasopressor-free days and ventilator-free days, without significant differences to those in the "Septic Shock" group, but significantly different to those in the Sepsis group. Multivariable logistic regression identified the maximum dose of vasopressor therapy used and serum lactate level as the major explanatory variables of mortality rates. However, the highest AUROC was for the maximum vasopressor therapy dosage used when compared to serum lactate level.
The Sepsis 3.0 criteria for septic shock may exclude approximately one-third of patients with similar clinical severity, poor outcomes, and mortality rate, which should be equally addressed.
Further studies are needed to identify a subset of COVID-19 patients, who were not initially admitted to the ICU, despite persistent hypotension with vasopressor requirements, and describe their clinical course and outcomes, further demonstrating a potential need to redefine the septic shock criteria in COVID-19 patients in order to maximize early recognition and prompt adequate surveillance and support.