• Users Online: 223
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 23  |  Issue : 2  |  Page : 95-100

Septic shock in patients admitted to intensive care unit with COVID-19 pneumonia


1 Department of Anaesthesiology and Intensive Care, Izmir Tepecik Training and Research Hospital, Izmir, Turkey
2 Department of Infectious Diseases and Clinical Microbiology, Izmir Tepecik Training and Research Hospital, Izmir, Turkey

Date of Submission02-Sep-2020
Date of Decision11-Sep-2020
Date of Acceptance27-Sep-2020
Date of Web Publication12-Aug-2021

Correspondence Address:
Dr. Nimet Senoğlu
Department of Anesthesiology and Reanimation, Division of Intensive Care Medicine, Izmir Tepecik Training and Research Hospital, Izmir
Turkey
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejop.ejop_101_20

Rights and Permissions
  Abstract 


BACKGROUND: The aim of this study was to determine mortality rates and to evaluate clinical features of coronavirus disease 2019 (COVID-19) patients with septic shock in intensive care unit (ICU).
MATERIALS AND METHODS: The medical records of COVID-19 patients requiring ICU admission were retrospectively reviewed over a 3-month period.
RESULTS: Forty patients with COVID-19 admitted to the ICU were screened. Two patients died within 24 h after ICU admission. After these patients were excluded, septic shock was detected in 11 (28%) of 38 patients during the 30-day follow-up period. Ten (91%) of the 11 patients with septic shock died in the ICU. Eight (72%) of the 11 patients had nosocomial infection during 30-day follow-up period. Six (54%) of 11 septic shock patients had positive culture results for bacterial pneumonia on the day of septic shock. The median time from symptom onset to septic shock was 14 (5–34) days. The median duration from ICU admission until septic shock was 8 (1–28) days. All of the patients with septic shock underwent invasive mechanical ventilation (IMV).
CONCLUSION: COVID-19 patients with septic shock have higher mortality rates, percentage of nosocomial infection, and IMV requirement.

Keywords: Acute disease, COVID-19, critical illness, intensive care, septic shock


How to cite this article:
Rollas K, Ersan G, Zincircioğlu &, Sahar I, Çalişkan T, Güldogan IK, Saritaş A, Uzun U, Senoğlu N. Septic shock in patients admitted to intensive care unit with COVID-19 pneumonia. Eurasian J Pulmonol 2021;23:95-100

How to cite this URL:
Rollas K, Ersan G, Zincircioğlu &, Sahar I, Çalişkan T, Güldogan IK, Saritaş A, Uzun U, Senoğlu N. Septic shock in patients admitted to intensive care unit with COVID-19 pneumonia. Eurasian J Pulmonol [serial online] 2021 [cited 2021 Dec 8];23:95-100. Available from: https://www.eurasianjpulmonol.com/text.asp?2021/23/2/95/320426




  Introduction Top


Coronavirus disease 2019 (COVID-19) has affected more than 20,000,000 individuals and caused nearly 770,000 deaths as of late August 2020.[1] Five percent of patients may require intensive care unit (ICU) admission and mechanical ventilation (MV).[2],[3],[4],[5],[6]

The frequency of shock in patients with COVID-19 ranges between 1% and 35%.[3],[4] The real incidence of septic shock in COVID patients is unknown. In one study, 70% of nonsurvivors of COVID-19 patients had septic shock indicating that septic shock is a common cause of death in COVID-19 patients with critical illness.[5]

There are limitations of the available data on risk factors associated with shock.[7],[8],[9] However, older age, comorbidities as hypertension, diabetes mellitus, and cardiac diseases, and lymphocytopenia have been considered as risk factors associated with shock.[2],[4],[8],[9] Studies on septic shock in patients with COVID-19 are lacking. The aim of this study was to determine mortality rates and evaluate clinical features of COVID-19 patients with septic shock.


  Materials and Methods Top


Patients

We retrospectively reviewed the records of all patients admitted to the ICU of a tertiary referral hospital between March 15, 2020, and June 15, 2020, with a diagnosis of COVID-19. Patients with clinical and radiological features of COVID-19 and positive real-time polymerase chain reaction (PCR) and/or positive antibody test results for coronavirus were included in the study. Patients who died within 24 h of ICU admission were excluded from the study.

Clinical data were obtained from medical and radiological imaging records. These data included age, sex, Acute Physiology and Chronic Health Evaluation (APACHE) II scores, Sequential Organ Failure Assessment (SOFA) scores, Glasgow Coma Scores, comorbidities, nosocomial infections, medications, duration of invasive mechanical ventilation (IMV), time from symptom onset to ICU admission and septic shock, duration of hospital and ICU stay, laboratory tests (blood chemistry, procalcitonin [PCT], C-reactive protein (CRP), arterial blood gas, and complete blood count), culture results of blood, bronchial secretions, urine samples, and medications. The study was approved by the local ethics committee of Tepecik Training and Research Hospital (no: 2020/6-1).

Definitions

Medical records of the patients were reviewed by an infectious disease specialist and intensivist. Patients were screened whether they had septic shock and concomitant nosocomial infections during the 30-day of ICU stay or until dead or discharge. Patients were divided into two groups as COVID-19 infection with septic shock and without septic shock. Nosocomial infection and types of nosocomial infection were defined according to the “Center for Disease Control and Prevention” recommendations on definition for specific types of infection.[10] Septic shock was defined according to “The Third International Consensus Definitions for Sepsis and Septic Shock.”[11]

Statistical analysis

Data were presented as number of cases, percentage, and median (minimum and maximum). Categorical comparisons were performed by Chi-square test. The Mann–Whitney U-test was applied to compare continuous variables. The Wilcoxon signed-rank test was used to test differences of paired data. A P < 0.05 was considered statistically significant. Data analysis was performed using SPSS software version 15.0 (SPSS Inc., Chicago, IL, USA).


  Results Top


During the 3-month period, forty COVID-19 patients were admitted to our ICU. Two patients died within 24 h after ICU admission. After these patients were excluded, 38 COVID-19 patients were included in the study. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) real-time PCR test was positive in 36 patients of the study population. In two patients whose SARS-CoV-2 real-time PCR test, results were negative had positive immunoglobulin M antibody test results for coronavirus. Septic shock was detected in 11 (28%) of 38 patients during the 30-day follow-up period.

The characteristics and clinical features of COVID-19 patients with or without septic shock are shown in [Table 1]. The median age of the patients with septic shock was 74 (57–79) years. Four of these patients were male and seven were female. There was no differences in age and gender between patients with septic shock and without septic shock. The median APACHE II score was 18 (11–31) in patients with septic shock and 13 (10–29) in patients without septic shock (P = 0.07). The median SOFA score was 5 (3–11) in patients with septic shock and 4 (2–13) in patients without septic shock (P = 0.05). Of the 11 patients with septic shock, four had hypertension, two had diabetes, three had cardiac disease, two had malignancy, two had neurologic disease, and one had chronic obstructive lung disease history. Eight (72%) patients in septic shock group and five (18%) without septic shock had nosocomial infections during ICU stay (P < 0.01). Eleven (100%) patients with septic shock and 7 (26%) without septic shock received IMV during the 30-day follow-up period (P < 0.01). Ten (91%) patients with septic shock and 4 (14%) without septic shock died in the ICU (P < 0.01).
Table 1: Baseline characteristics of Coronavirus disease 2019 patients with and without septic shock

Click here to view


The clinical and laboratory features of COVID-19 patients with septic shock on the 1st day of ICU stay and on the day of septic shock are shown in [Table 2]. SOFA score, leukocyte, neutrophil levels, PCT, CRP, and creatinine were higher on the day of septic shock (P < 0.01, P < 0.01, P < 0.01, P < 0.01, P = 0.02, and P = 0.02, respectively). Among SOFA score determinants, renal and cardiovascular score was higher on the day of septic shock detected. Hemoglobin and albumin were lower on the day of septic shock (P = 0.02 and P < 0.01, respectively). The median time from symptom onset to septic shock was 14 (5–34) days. The median duration from ICU admission until initiation of septic shock was 8 (1–28) days. The median duration from IMV to septic shock was 3 (1–20).
Table 2: The clinical features of Coronavirus disease 2019 patients with septic shock on the 1st day of intensive care unit stay and on the day of septic shock

Click here to view


Eight (72%) of 11 septic shock patients had nosocomial infection including bacteremia and ventilator-associated pneumonia, hospital-acquired pneumonia, candidemia, and aspergillosis during the 30-day follow-up period [Table 3]. Six (54%) of 11 septic shock patients had positive culture results including Acinetobacter spp., Corynebacterium spp., Klebsiella pneumonia, Pseudomonas aeruginosa, and Haemophilus influenzae on the day of septic shock [Table 3].
Table 3: Clinical features of Coronavirus disease 2019 patients with septic shock admitted to intensive care unit

Click here to view



  Discussion Top


In our retrospective study, COVID-19 patients with septic shock had higher nosocomial infection, MV requirement, and mortality rates compared to COVID-19 patients who did not develop septic shock.

Twenty-eight percent (11/38) of critically ill COVID-19 patients developed clinical signs of shock including hypotension requiring vasopressor and high lactate level. These patients met the diagnostic criteria for septic shock according to the “Third International Consensus Definitions for Sepsis and Septic Shock.”[11] SOFA score reflects state of organ dysfunctions.[11] The total SOFA score determinanats include respiratory, renal, hepatic, cardiovascular, hematologic, and neurologic status scores. Among these, besides cardiovascular score, renal score was higher on the day of septic shock than at the admission in our septic shock patients, indicating that these patients are susceptible to acute kidney injury.

In a retrospective study, Zhou et al. found that COVID-19 patients who died had statistically significant prevalence of sepsis (100% vs. 42%) and septic shock (70% vs. 0%) compared to patients who survived (P < 0.0001 and P < 0.0001).[5] As 91% (n = 10) of our COVID-19 patients with septic shock died in ICU, septic shock seems to be a leading cause of death in our COVID-19 patients.

Secondary infections are not uncommon among the patients with COVID-19.[3],[6],[7],[8] The contribution of secondary infections to outcomes in patients with COVID-19 is still not well known. Huang et al. reported that 10% (4/41) of COVID-19 patients had secondary infection.[6] Yu et al. found that 49% of COVID-19 patients in ICU had hospital-acquired bacterial infection or fungal infection.[7] In another study, 16% (11/68) of COVID-19 patients who died had secondary infection.[8] In a study in Wuhan, China, 50% of the patients who died in hospital (n = 54) had secondary infection.[5] In our study, 13 of 38 patients had secondary infection, and percentage of secondary infection in septic shock group was higher than patients without septic shock.

In previous studies, microorganisms that cause sepsis have been identified in 59%–69% of septic patients.[12],[13],[14],[15] Seventy percent of documented sepsis is attributable to bacterial organisms.[13],[14],[15] Critically ill patients are susceptible to nosocomial bacterial infections,[16] and secondary bacterial infections may occur after viral infections; therefore, it is difficult to determine whether the cause of septic shock is viral or secondary/nosocomial bacterial infection in critically ill patients with pneumonia due to viral infection.[7],[15] However, in contrast to viral infections, elevated PCT levels are expected to be seen in bacterial infections.[17] Increase in PCT and neutrophil count was found in our septic shock patients. In addition, high percentage of positive culture results for bacteria shows that nosocomial bacterial infection may be an important cause of septic shock in our patients.

Lymphocytopenia has been found to be associated with an increased risk of acquired infection in ICU, the probability of 28-day septic shock and 28-day mortality in previous studies.[18],[19] It is widely known that lymphocytopenia is a commoon finding in COVID-19 patients.[2],[3],[4],[5],[6] In our study, low lymphocyte count was found in most of patients and remain unchanged on the day of septic shock when compared with the lymphocyte count on the 1st day.

All of the patients who had septic shock received MV in our patients. Ventilatory support is a risk factor for ICU-acquired infections including ventilator-associated pneumonia.[16] Not surprisingly, in a report from the USA, bacteremia and requirement of vasopressor support were found to be high in mechanically ventilated COVID-19 patients (11% vs. 1.8% and 95.4% vs. 1.5%, respectively).[20] The mortality rate in our COVID-19 patients with septic shock requiring MV admission was higher compared to patients without septic shock.


  Conclusion Top


COVID-19 patients with septic shock have higher mortality rates and percentage of nasocomial infections and IMV requirements. Although it is difficult to distinguish from viral septic shock, nosocomial bacterial infection may be an important cause of septic shock development in COVID-19 patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization Website. Coronavirus Disease (COVID-2019) Situation Reports. Geneva: World Health Organization; 2020.  Back to cited text no. 1
    
2.
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72 314 cases from the Chinese center for disease control and prevention. JAMA 2020;323:1239-42.  Back to cited text no. 2
    
3.
Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020;382:1708-20.  Back to cited text no. 3
    
4.
Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and out- comes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81.  Back to cited text no. 4
    
5.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.  Back to cited text no. 5
    
6.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 6
    
7.
Yu Y, Xu D, Fu S, Zhang J, Yang X, Xu L, et al. Patients with COVID-19 in 19 ICUs in Wuhan, China: A cross-sectional study. Crit Care 2020;24:219.  Back to cited text no. 7
    
8.
Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med 2020;46:846-8.  Back to cited text no. 8
    
9.
Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving sepsis campaign: Guidelines on the management of critically Ill adults with coronavirus disease 2019 (COVID-19). Crit Care Med 2020;48:440-69. [doi: 10.1097/CCM. 0000000000004363].  Back to cited text no. 9
    
10.
Centers for Disease Control and Prevention; National Healthcare Safety Network. CDC/NHSN Surveillance Definitions for Specific Types of Infection. 2019. Available from: http://www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf. [Last accessed on 2020 Jul 30].  Back to cited text no. 10
    
11.
Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315:801-10.  Back to cited text no. 11
    
12.
Phua J, Ngerng W, See K, Tay C, Kiong T, Lim H, et al. Characteristics and outcomes of culture-negative versus culture-positive severe sepsis. Crit Care 2013;17:R202.  Back to cited text no. 12
    
13.
Zahar JR, Timsit JF, Garrouste-Orgeas M, Français A, Vesin A, Vesim A, et al. Outcomes in severe sepsis and patients with septic shock: Pathogen species and infection sites are not associated with mortality. Crit Care Med 2011;39:1886-95.  Back to cited text no. 13
    
14.
Blanco J, Muriel-Bombín A, Sagredo V, Taboada F, Gandía F, Tamayo L, et al. Incidence, organ dysfunction and mortality in severe sepsis: A Spanish multicentre study. Crit Care 2008;12:R158.  Back to cited text no. 14
    
15.
Lin GL, McGinley JP, Drysdale SB, Pollard AJ. Epidemiology and immune pathogenesis of viral sepsis. Front Immunol 2018;9:2147.  Back to cited text no. 15
    
16.
Vincent JL, Bihari D, Suter P, Bruining HA, White J, Nicolas-Chanoin MH, et al. The prevalence of nosocomial infection in intensive care units in Europe. EPIC study. J Am Med Assoc 1995;274:639-44.  Back to cited text no. 16
    
17.
Schuetz P, Amin DN, Greenwald JL. Role of procalcitonin in managing adult patients with respiratory tract infections. Chest 2012;141:1063-73.  Back to cited text no. 17
    
18.
Adrie C, Lugosi M, Sonneville R, Souweine B, Ruckly S, Cartier JC, et al. Persistent lymphopenia is a risk factor for ICU-acquired infections and for death in ICU patients with sustained hypotension at admission. Ann Intensive Care 2017;7:30.  Back to cited text no. 18
    
19.
Sheikh Motahar Vahedi H, Bagheri A, Jahanshir A, Seyedhosseini J, Vahidi E. Association of lymphopenia with short term outcomes of sepsis patients; a brief report. Arch Acad Emerg Med 2019;7:e14.  Back to cited text no. 19
    
20.
Goyal P, Choi JJ, Pinheiro LC, Schenck EJ, Chen R, Jabri A, et al. Clinical characteristics of Covid-19 in New York City. N Engl J Med 2020;382;2372-4.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  Materials and Me...
  In this article
Abstract
Introduction
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed1023    
    Printed98    
    Emailed0    
    PDF Downloaded113    
    Comments [Add]    

Recommend this journal