VU Research Portal
Improving the acute care for critically ill patients
Alam, N.
2018
document version
Publisher's PDF, also known as Version of record
Link to publication in VU Research Portal
citation for published version (APA)
Alam, N. (2018). Improving the acute care for critically ill patients: Consider the chain as a whole.
General rights
Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain
• You may freely distribute the URL identifying the publication in the public portal ?
Take down policy
If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim.
E-mail address:
C H A P T E R
8
LONG-TERM HEALTH RELATED
QUALITY OF LIFE IN PATIENTS WITH
SEPSIS AFTER INTENSIVE CARE STAY:
A SYSTEMATIC REVIEW
Acute Med. 2017;16(4):164-169
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
ABSTRACT
Sepsis is a major health care issue and sepsis survivors are often confronted with long-term
complications after admission to the intensive care unit (ICU) which may negatively
influence their health related quality of life (HRQOL). This study aimed to systematically
evaluate the outcome in terms of HRQOL in patients with sepsis after ICU discharge.
A literature search was conducted in the bibliographic databases PubMed,
EMBASE, and CINAHL, including reference lists of published guidelines, reviews and
associated articles.
Sixteen studies were included, thirteen (81.3%) reported that sepsis survivors suffer
from impaired HRQOL in physical and mental domains which persist months until years
after a sepsis episode.
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
INTRODUCTION
Sepsis is considered a serious threat to public health, with a high incidence, and
continues to rise. This is mainly due to an aging population, an increased use of
chemo- and immunotherapy and antibiotic resistance (1). Patients with severe sepsis have
high morbidity and mortality rates, predominantly caused by acute organ dysfunction.
The need for vital organ support often necessitates admission to the intensive care unit
(ICU) and prolonged use of these (costly) healthcare facilities (2). The incidence of severe
sepsis in the ICU, either acquired at admission or during ICU stay, has also increased
and currently 11% to 15% of all ICU patients have a diagnosis of severe sepsis or septic
shock (3-5).
Survivors of ICU may suffer from impairments in physical (e.g. critical illness neuropathy,
chronic pain) and mental (e.g. cognitive impairment, depression) health and these
impairments may have extensive effects on the health-related quality of life (HRQOL)
(6-9). Recent work has underlined this by stating (10) that elderly patients admitted to
a medical ICU have a low survival rate (49%) up to 12 months after discharge. Moreover,
these elderly survivors had a twofold increase in the prevalence of geriatric syndromes
(mainly polypharmacy, urinary incontinence and depression), even at long-term
follow–up. These impairments could negatively influence the HRQOL.
In the past, critical care research has mainly focused on outcomes such as (short-
term) mortality, however considering the profound impact sepsis and ICU admission
might have, recently more attention is being paid to HRQOL as an equally important
outcome. A review regarding HRQOL after stay at ICU in patients with critical illnesses was
performed in 2010 by Oeyen et al (11). This study focused on multiple critical illnesses,
of which sepsis related studies were a relatively small group. Only three of the 53 studies
included, solely focused on septic patients. The authors found that HRQOL differed with
each diagnostic category and that patients with severe sepsis, amongst other diagnoses
(such as severe acute respiratory distress syndrome) had the most severe setback in
HRQOL. Only one review (12) primarily focusing on long-term mortality and HRQOL in all
patients with sepsis has been published in 2010. This work demonstrated that patients
with sepsis were found to have ongoing mortality, even years after an episode of sepsis
and moreover survivors suffered from impaired HRQOL. Thus, both ICU survivors and
survivors of sepsis, may suffer for months or years from long lasting impairments that
arise during or after their lengthy stay in the intensive care and hospital.
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
MATERIAL AND METHODS
Study identification / search strategy
To identify all relevant publications, we performed a systematic search in the bibliographic
databases PubMed, EMBASE, and CINAHL from inception to July 2016. Search terms
included free text terms as well as controlled terms from MeSH in PubMed and
The Cochrane Library, EMtree in EMBASE and Thesaurus in CINAHL. In PsychINFO only
free text terms were used. Search terms expressing ‘sepsis’ were used in combination
with search terms comprising ‘quality of life’. Filters were applied where possible to
limit the results to adults, and to exclude certain publication types such as newspaper
articles and case reports. The search strategy can be found in the supplementary
appendix. Subsequently, the references of identified articles were manually searched for
relevant publications.
Eligibility Criteria
An extensive number of studies (n= 3085) was extracted during this search. Thereafter, all
titles were reviewed for an initial screening to identify the studies that could potentially
contain longitudinal data involving long-term outcomes of patients with sepsis,
subsequently an abstract selection was performed. Studies were selected for review if
they met the following inclusion criteria: (i) the study was a retrospective, a prospective
observational, or a case-controlled study; (ii) the study population consisted of patients
(age 18 years and above) admitted to the ICU with sepsis; (iii) the study reported HRQOL
as a (primary) outcome; (iv) HRQOL assessment tools were used. Exclusion criteria were:
(i) no full text available (in English); (ii) certain publication types such as editorials, letters,
legal cases, interviews, posters etc.
Study selection and Data Collection
Three reviewers (NA, RN, JH) independently screened all potentially relevant titles and
abstracts for eligibility. If necessary, the full text article was checked for the eligibility criteria.
Differences in opinions were resolved by consensus. All retrieved abstracts were available
in English. Data was extracted independently from the selected articles, a standardized
data-worksheet including the following variables was used for data extraction: type of
study, patient characteristics, methodology, study outcomes, conclusion, limitations, and
study quality.
Quality assessment data
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
RESULTS
Study Characteristics
Of the total 3085 citations were identified, 16 articles were included (Figure 1. Flow
chart). A total of 5333 septic patients and hospitalized controls were enrolled in
the 16 included studies. A total number of included patients in the control group
cannot be provided as some studies did not mention the sample size of the control
group (17-22), which consisted of controls of the general population or an age and/or
gender-matched population. Table 1 gives a complete overview of the characteristics in
the reviewed studies.
Setting
The 16 included studies took place in hospitals across different countries, from which
eleven in Europe (65%) (17-27), two in North America (28, 29), one in South America
Excluded duplicates: n=544
Excluded abstracts: n=63
not applicable based on eligibility criteria Records selected for abstracts review
n=105
Excluded titles: n=3233
Do not concern sepsis and quality of life
Excluded articles: n=26 - no full text available, n=7 - full text not available in English, n=4 - not applicable based on eligibility criteria, n=15
Articles included in qualitative synthesis n=16
Records identified through database search n = 3882 PubMed: 1543
EMBASE: 2137 CINAHL: 202
Records selected for title review n= 3338
Full-text articles assessed for eligibility n=42
Ide
nti
fic
at
io
n
Sc
reen
in
g
Elig
ib
ilit
y
Inc
lude
d
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
(30), one in Asia (31). One study took place in both Europe and North America (32).
The publication dates of these studies ranged from 1995 until 2015. Five studies included
patients from a medical/surgical intensive care unit (M/SICU) (17, 21, 26, 27, 30), four
included patients from a surgical intensive care unit (SICU) (23-25, 31) and seven studies
included patients from a general ICU (18-20, 22, 28, 29, 32). Nine studies (17, 19, 21,
23-26, 29, 30) were single centre, five multi-centre (18, 20, 27, 31, 32) and of two
studies (22, 28) the number of participating centres remained unclear.
Sepsis type
All studies used the international criteria (from the International Sepsis Definitions
Conference) to define sepsis (33). Two studies (28, 29) included patients in categories of
sepsis, severe sepsis and septic shock. Six studies (18, 23-27) had a population of patients
with either severe sepsis or septic shock, while six studies (17, 20, 22, 30-32) only focused
on patients with severe sepsis and two on patients with septic shock only (19, 21). Three
studies had a population which consisted of patients with sepsis of a specific organ
system, namely abdominal (23, 24) and community acquired sepsis (27).
Quality of life assessment methods
The majority of the studies used standardized instruments to measure the HRQOL. An
overview of the different methods used to assess HRQOL can be found in the supplementary
appendix. The EuroQol five dimensions questionnaire (EQ-5D) and the Short-Form 36
(SF-36) were most frequently used, whereas some studies used alternative methods of
assessment to calculate HRQOL. The EQ-5D was used in seven studies (43.8%) (18, 20,
25-27, 30, 32) and the SF-36 in six studies (37.5%) (17, 19-21, 28, 31), see Table 3
Assessment of HRQOL.
Assessment of HRQOL.
HRQOL was assessed by patients themselves, proxies or a combination in respectively
43.8% (19, 20, 22, 24, 26-28), 6.2% (23), 50% (17, 18, 21, 25, 29-32) of the studies.
During follow-up, HRQOL of patients was evaluated in two studies (26, 31) through
personal interviews, in five studies through mail (18, 22, 23, 27, 29), in four studies (20,
25, 28, 30), by telephone and in five studies (17, 19, 21, 24, 32) a combination was used.
Response rate and follow-up
A minority of the studies (17, 21, 26, 27) used a follow-up period of six months, while
the remaining twelve studies (18-20, 22-24, 28-32) used a follow-up period which ranged
from one to eight years (see Table 3.) .
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
Quality of life outcomes
Majority (81.3%) of the included studies reported survivors of sepsis suffer from an
impaired quality of life (17-22, 24, 25, 28-32). An overview of the findings concerning
HRQOL per study can be found in table 3. Four studies comparing HRQOL with other
critically ill ICU survivors without sepsis, found that sepsis survivors have a similar HRQOL
(25-27, 31). Twelve studies (17-22, 26-31) which compared HRQOL of sepsis survivors
with that of a general or age- and/or gender matched population, found significant
reductions in HRQOL, in physical as in social domains of life. Both McLauchlan23 and
Haraldsen (24) et al., who specifically investigated HRQOL after abdominal sepsis, found
that functional status of survivors restored and QOL was reasonable at time of
follow-up. Overall, although some recovery was reported (23, 24), the decline in HRQOL could
persist many months until years after an episode of sepsis (17, 20, 21).
Mortality
Eleven of the sixteen studies (17-21, 23-28) provided hospital mortality data. Hospital
mortality rates varied from 10% to 63%. Eight studies (17, 18, 20, 21, 24, 26-28) had
an in-hospital mortality rate varying from 10 to 50%, while two studies (23, 25) had an
in-hospital mortality rate of over 50%. Eight studies (17, 18, 20, 21, 23, 25-27) provided
ICU mortality rate of the sepsis group, which ranged between 11.9% to 48%.
Accumulated mortality after discharge was measured at one or more time points after
discharge. In three studies (17, 21, 26) mortality was measured up to 6 months after
discharge. In these groups, mortality rate was between 30 and 45%. Seven studies (18,
20, 24, 25, 29-31) looked at long-term mortality up to 5 years after discharge and their
mortality rates ranged between 9.5% and 67%. Heyland et al. (28) found a mortality
after discharge of 40% and Poulsen et al. (19) a mortality of 53%, but both studies did
not disclose the time point at which mortality was measured. The remainder of the studies
(22, 23, 32) did not provide information on mortality after discharge of the sepsis group.
Study quality criteria
One study 18 (6.3%) met all of the four predefined study quality criteria as adapted
from the U.S. Preventive Services Task Force 15, 16. Seven studies 17, 19, 21, 22, 25,
28, 30 (43.8%) fulfilled three of the four quality criteria. Two studies (26, 31) had
major exclusion criteria, excluding more than 10% of the patients, whilst four studies
(17, 27, 29, 32) did not adequately describe their exclusion criteria. See table 4. Study
quality criteria.
DISCUSSION
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
Table 1. Patient Characteristics Author
Year Country Study Design Inclusion Period Setting Sepsis type Study group size (n) Eligible patients for QOL assessment (n) Sepsis Group, (n) Control Group (n)
McLauchlan, 1995 United Kingdom Retrospective, observational Jan 1990 - Jun 1993 SICU, SC AS,SS, SH 125 41 125 -Heyland, 2000 Canada Cross sectional survey 1993-1998 ICU, U S, SS, SH 379 44 at 1st interview
30 at 2nd interview
78 General US population (n=2474) and patients with chronic illness (n=301)
Haraldsen, 2002 Sweden Retrospective, observational cohort
Jan 1983– Dec 1995 SICU, SC AS,SS, SH 210 106 210 Granja, 2004 Portugal Prospective, observational
Cross sectional
Mar 1997– Mar 2001 M/SICU, SC SS, SH 697 391 (184 sepsis, 133 controls) 305 ICU admissions without sepsis (n= 305)
Korosec, 2006 Slovenia Prospective, observational Jan 2003 - Dec 2003 SICU, SC SS, SH 164 78 (21 sepsis, 57 trauma) 66 Trauma patients ICU (98) Hofhuis, 2008 The Netherlands Prospective, observational Sep 2000- Apr 2004 M/SICU, SC SS U * 170 at ICU admission
123 at ICU discharge 101 at hospital discharge
96 at 3 months after ICU discharge 95 at 6 months after ICU discharge
170 Age matched general Dutch population
Karlsson, 2009 Finland Prospective, observational cohort Nov 2004–Feb 2005 ICU, MC SS, SH 470 470 QOL before 278 long-term QOL
470 Age-and gender-adjusted Finnish population Poulsen, 2009 Denmark Prospective, observational Apr 2006-Mar 2007 ICU, SC SH 172 78 172 Age- and gender-matched
Danish population (n=494) Lazosky, 2010 Canada Prospective, observational U ICU, SC S, SS, SH 45 43 (19 sepsis, 24 cardiac) 21 Age-matched cardiac patients
(n=24) Contrin, 2013 Brasil Retrospective, observational
Case control
May 2004–Dec 2009 M/SICU, SC SS 349 296 (152 sepsis, 144 controls) 185 Patients without sepsis admitted immediately after each septic ICU admission (n=164) Cuthbertson,
2013
Scotland Prospective, observational cohort Apr 2003 – Oct 2003 ICU, MC SS 439 185 (3.5 years after ICU admission) 172 (5 years after ICU admission)
439 Age and gender-matched population
Nesseler, 2013 France Prospective, observational Oct 2008 –Dec 2010 M/SICU, SC SH 96 U at 48 hours after occurrence of sepsis 51 at 180 days
93 General French population
Orwelius, 2013 Portugal Prospective, observational Jan 2005–Jun 2005 M/SICU, MC CAS, SS, SH 935 599 U c ICU admissions without sepsis c Rosendahl, 2013 Germany Prospective, observational
cross- sectional
2002 - 2010 ICU, U SS 564 564 55 Age and gender-matched German population Zhang, 2013 China Prospective Case control Jan 2003 - Dec 2008 SICU, MC SS 479 146 (66 sepsis, 80 controls) 112 Non-septic ICU patients,
(n=112)
Gender-matched community controls, (n= 126)
Gallop, 2015 United Kingdom and the United States
Retrospective, observational U ICU, MC SS 39 39 (22 patients, 17 informal caregivers)
22
-AS= abdominal sepsis, C-AS= community acquired sepsis, MC = multi-center, SICU= surgical intensive care unit, M/SICU= medical/surgical intensive care unit, S= sepsis, SS= severe sepsis, SH= septic shock, SC= single center, U= unknown, a6768
patients with 7094 hospitalizations during the study period; b1194 patients with 1520 hospitalizations during the study period,
c Exact number of the sepsis group and control is not mentioned in the article. However, it is known that 599 patients in total
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
Table 1. Patient Characteristics Author
Year Country Study Design Inclusion Period Setting Sepsis type Study group size (n) Eligible patients for QOL assessment (n) Sepsis Group, (n) Control Group (n)
McLauchlan, 1995 United Kingdom Retrospective, observational Jan 1990 - Jun 1993 SICU, SC AS,SS, SH 125 41 125 -Heyland, 2000 Canada Cross sectional survey 1993-1998 ICU, U S, SS, SH 379 44 at 1st interview
30 at 2nd interview
78 General US population (n=2474) and patients with chronic illness (n=301)
Haraldsen, 2002 Sweden Retrospective, observational cohort
Jan 1983– Dec 1995 SICU, SC AS,SS, SH 210 106 210 Granja, 2004 Portugal Prospective, observational
Cross sectional
Mar 1997– Mar 2001 M/SICU, SC SS, SH 697 391 (184 sepsis, 133 controls) 305 ICU admissions without sepsis (n= 305)
Korosec, 2006 Slovenia Prospective, observational Jan 2003 - Dec 2003 SICU, SC SS, SH 164 78 (21 sepsis, 57 trauma) 66 Trauma patients ICU (98) Hofhuis, 2008 The Netherlands Prospective, observational Sep 2000- Apr 2004 M/SICU, SC SS U * 170 at ICU admission
123 at ICU discharge 101 at hospital discharge
96 at 3 months after ICU discharge 95 at 6 months after ICU discharge
170 Age matched general Dutch population
Karlsson, 2009 Finland Prospective, observational cohort Nov 2004–Feb 2005 ICU, MC SS, SH 470 470 QOL before 278 long-term QOL
470 Age-and gender-adjusted Finnish population Poulsen, 2009 Denmark Prospective, observational Apr 2006-Mar 2007 ICU, SC SH 172 78 172 Age- and gender-matched
Danish population (n=494) Lazosky, 2010 Canada Prospective, observational U ICU, SC S, SS, SH 45 43 (19 sepsis, 24 cardiac) 21 Age-matched cardiac patients
(n=24) Contrin, 2013 Brasil Retrospective, observational
Case control
May 2004–Dec 2009 M/SICU, SC SS 349 296 (152 sepsis, 144 controls) 185 Patients without sepsis admitted immediately after each septic ICU admission (n=164) Cuthbertson,
2013
Scotland Prospective, observational cohort Apr 2003 – Oct 2003 ICU, MC SS 439 185 (3.5 years after ICU admission) 172 (5 years after ICU admission)
439 Age and gender-matched population
Nesseler, 2013 France Prospective, observational Oct 2008 –Dec 2010 M/SICU, SC SH 96 U at 48 hours after occurrence of sepsis 51 at 180 days
93 General French population
Orwelius, 2013 Portugal Prospective, observational Jan 2005–Jun 2005 M/SICU, MC CAS, SS, SH 935 599 U c ICU admissions without sepsis c Rosendahl, 2013 Germany Prospective, observational
cross- sectional
2002 - 2010 ICU, U SS 564 564 55 Age and gender-matched German population Zhang, 2013 China Prospective Case control Jan 2003 - Dec 2008 SICU, MC SS 479 146 (66 sepsis, 80 controls) 112 Non-septic ICU patients,
(n=112)
Gender-matched community controls, (n= 126)
Gallop, 2015 United Kingdom and the United States
Retrospective, observational U ICU, MC SS 39 39 (22 patients, 17 informal caregivers)
22
-AS= abdominal sepsis, C-AS= community acquired sepsis, MC = multi-center, SICU= surgical intensive care unit, M/SICU= medical/surgical intensive care unit, S= sepsis, SS= severe sepsis, SH= septic shock, SC= single center, U= unknown, a6768
patients with 7094 hospitalizations during the study period; b1194 patients with 1520 hospitalizations during the study period,
c Exact number of the sepsis group and control is not mentioned in the article. However, it is known that 599 patients in total
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
Table 2. Patient Characteristics and Outcomes
Author Group (n) Male, % Age, Years, median (IQR), mean ± SD Mean APACHE II Score (range) % (n)ICU Mortality Hospital Mortality, % (n) Long term mortality, % (months) ICU LOS days, median (IQR) , mean ± SD Hospital LOS days, median (IQR), mean ± SD
McLauchlan SG, (125) 49 68 (22-88) 22 (7-48) 48(60) 63 (79) U 6 (1-56) 17 (1-306) Heyland SG (78) - - - - 35(27) 40(U) 12.03 ± 8.87 32.73 (18.0) R-SG (30) 53 62± 13.7 22.47 +6.04 - - - - -Haraldsen SG (210) - - - - 28(59) 35 (12), 39 (24), 44(60) - -R-SG (49) - 67 (27-88) 11.17 (5.15) - - - 6 (1-128) 23 (6-244) Granja SG (305) - - - 25 (75) 34(103) 40 (6) - -R-SG (104) 64 52 (38-66) 17 (13-21) - - - 8 (4-11) -CG (304) - - - 19 (59) 26(79) 32 (6) - -R-CG (133) 54 58 (42-69) 12 (8-18) - - - 3 (3-5) -Korosec SG (66) 49 64.4±13.5 15.5 ± 6.4 40 (26) 58 (38) 67 (24) 11.8 ±16.1 -CG (98) 71 53.2 ±21.5 14.3 ±6.6 26(25) 38(37) 43 (24) 11.9 ±12.5 -Hofhuis SG (170) 63.5 70 (62-77) 21(17-25) 28 (47) 36(61) 38.8(3), 39.4(6) 12 (7-22) 24 (16-48) Karlsson SG (470) - - - 15.5 (73) 28.3 (133) 40.9 (12), 44.9 (24) - -R-SG at T1 (252) 64.7 60.4 ±14.3 24(18-29) 11.9 (30) 23.4(59) - 6 (4-13) 18 (11-34) R-SG at T2 (156) 73.1 58.6 ±15.8 22 (17-28) - - - 6 (4-12) 21 (12-35) Poulsen TG (172) - - - 34(58) 46 (79) 53 a - -S-SG (70) 78 59 (46-67) - - - - 9 (5-16) 40 (26-81) NS -SG (92) 59 64 (52-72) - - - - 9 (4-22) 29 (14-56) Lazosky SG (21) 25b 49.6 (22-78) - - - 9.5 (12-48) - 28.5 (3-66) CG (24) 87 58.5(46-82) - - - 7 (2-12) Contrin SG (185) - - - - 36.5(12)c 10.8 ±9.5 24.2±15.3 R-SG (50) 64 51.3 ±20 - - - - 8 (1-38) 20 (3-68) CG (164) - - - 19.7(12)c 4.8 ±4.2 14.8 ±10.2 R-CG (50) 48 52.2 ±19.4 - - - - 3 (1-22) 14 (4-53) Cuthbertson SG (439) 53 58 (45-67) 23 (17-28) 37 (172) 43 (190) 58 (42) ; 61(60) 7.1 (2.7-15.8) 19 (8-41.2) Nesseler SG (93) 70 69 (61-78) - 28 (26) 32 (30) 45(6) - -S-SG (51) 67 67 (56-75) - - - - 12 (8-23) 41 (25-56) NS- SG (42) 79 72 (64-81) - - - - 12 (5-23) 27 (10-43) Orwelius R-SG (91) 65 60 (50-70) - - - - 10 (7-14) -R- CG (222) 56 59 (43-71) - 17 (113) 9 (62) 24 (6) 7 (4-11) -Rosendahl S- SG (55) 67 61.1(33-85d) - - - - 32 (14-56) -Zhang Gallop R-SG (42) 76 53.1±17.41 18.35 + 6.8 - - 41 (39.6 + 15) 10.5 (5.0-15.25) 40.0 (25.75-70.25) R-CG (33) R-SG (22) 70 36 47.0±18.2 56.0 (25-79) 13.7+ 6.5 -- -- -29 (37.2 + 15) -5.0 (3.0-6.0) 8.8 (1-27) 29.0 (20.5- 40.0) 24.6 (2-91)
IQR= Inter quartile range; SD= Standard deviation., LOS= Length of stay. ICU= intensive care unit. CG= control group, SG= sepsis group, S-SG= survivors sepsis group, NS-SG= non survivors sepsis group, R-CG= respondents control group, R-SG= respondents sepsis group, TG= total group, T1= first follow-up moment, T2= second follow-up moment. a Poulsen: long term
mortality assessed at time of follow up with a 1 year median and a 1 year range( 6-18 months) after septic shock; bLazosky:
Percentage of male patients in the study group is derived from the supplementary data of the study; c Contrin: mortality
percentages described in discussion, exact number of patients not given; d Rosendahl: age range obtained after mailing
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
Table 2. Patient Characteristics and Outcomes
Author Group (n) Male, % Age, Years, median (IQR), mean ± SD Mean APACHE II Score (range) % (n)ICU Mortality Hospital Mortality, % (n) Long term mortality, % (months) ICU LOS days, median (IQR) , mean ± SD Hospital LOS days, median (IQR), mean ± SD
McLauchlan SG, (125) 49 68 (22-88) 22 (7-48) 48(60) 63 (79) U 6 (1-56) 17 (1-306) Heyland SG (78) - - - - 35(27) 40(U) 12.03 ± 8.87 32.73 (18.0) R-SG (30) 53 62± 13.7 22.47 +6.04 - - - - -Haraldsen SG (210) - - - - 28(59) 35 (12), 39 (24), 44(60) - -R-SG (49) - 67 (27-88) 11.17 (5.15) - - - 6 (1-128) 23 (6-244) Granja SG (305) - - - 25 (75) 34(103) 40 (6) - -R-SG (104) 64 52 (38-66) 17 (13-21) - - - 8 (4-11) -CG (304) - - - 19 (59) 26(79) 32 (6) - -R-CG (133) 54 58 (42-69) 12 (8-18) - - - 3 (3-5) -Korosec SG (66) 49 64.4±13.5 15.5 ± 6.4 40 (26) 58 (38) 67 (24) 11.8 ±16.1 -CG (98) 71 53.2 ±21.5 14.3 ±6.6 26(25) 38(37) 43 (24) 11.9 ±12.5 -Hofhuis SG (170) 63.5 70 (62-77) 21(17-25) 28 (47) 36(61) 38.8(3), 39.4(6) 12 (7-22) 24 (16-48) Karlsson SG (470) - - - 15.5 (73) 28.3 (133) 40.9 (12), 44.9 (24) - -R-SG at T1 (252) 64.7 60.4 ±14.3 24(18-29) 11.9 (30) 23.4(59) - 6 (4-13) 18 (11-34) R-SG at T2 (156) 73.1 58.6 ±15.8 22 (17-28) - - - 6 (4-12) 21 (12-35) Poulsen TG (172) - - - 34(58) 46 (79) 53 a - -S-SG (70) 78 59 (46-67) - - - - 9 (5-16) 40 (26-81) NS -SG (92) 59 64 (52-72) - - - - 9 (4-22) 29 (14-56) Lazosky SG (21) 25b 49.6 (22-78) - - - 9.5 (12-48) - 28.5 (3-66) CG (24) 87 58.5(46-82) - - - 7 (2-12) Contrin SG (185) - - - - 36.5(12)c 10.8 ±9.5 24.2±15.3 R-SG (50) 64 51.3 ±20 - - - - 8 (1-38) 20 (3-68) CG (164) - - - 19.7(12)c 4.8 ±4.2 14.8 ±10.2 R-CG (50) 48 52.2 ±19.4 - - - - 3 (1-22) 14 (4-53) Cuthbertson SG (439) 53 58 (45-67) 23 (17-28) 37 (172) 43 (190) 58 (42) ; 61(60) 7.1 (2.7-15.8) 19 (8-41.2) Nesseler SG (93) 70 69 (61-78) - 28 (26) 32 (30) 45(6) - -S-SG (51) 67 67 (56-75) - - - - 12 (8-23) 41 (25-56) NS- SG (42) 79 72 (64-81) - - - - 12 (5-23) 27 (10-43) Orwelius R-SG (91) 65 60 (50-70) - - - - 10 (7-14) -R- CG (222) 56 59 (43-71) - 17 (113) 9 (62) 24 (6) 7 (4-11) -Rosendahl S- SG (55) 67 61.1(33-85d) - - - - 32 (14-56) -Zhang Gallop R-SG (42) 76 53.1±17.41 18.35 + 6.8 - - 41 (39.6 + 15) 10.5 (5.0-15.25) 40.0 (25.75-70.25) R-CG (33) R-SG (22) 70 36 47.0±18.2 56.0 (25-79) 13.7+ 6.5 -- -- -29 (37.2 + 15) -5.0 (3.0-6.0) 8.8 (1-27) 29.0 (20.5- 40.0) 24.6 (2-91)
IQR= Inter quartile range; SD= Standard deviation., LOS= Length of stay. ICU= intensive care unit. CG= control group, SG= sepsis group, S-SG= survivors sepsis group, NS-SG= non survivors sepsis group, R-CG= respondents control group, R-SG= respondents sepsis group, TG= total group, T1= first follow-up moment, T2= second follow-up moment. a Poulsen: long term
mortality assessed at time of follow up with a 1 year median and a 1 year range( 6-18 months) after septic shock; bLazosky:
Percentage of male patients in the study group is derived from the supplementary data of the study; c Contrin: mortality
percentages described in discussion, exact number of patients not given; d Rosendahl: age range obtained after mailing
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
Table 3. Assessment of quality of life (QOL)
Author
QOL assessment
Follow up period (IQR); mean ± SD Response Rate, n (% of QOL responders) Key Findings for QoL
Instrument Method Who
McLauchlan WHO -PS M Pr (GP) 15 (3-39) months After hospital discharge
32 (78%) · QoL at 15 months after discharge for severe abdominal sepsis survivors is good, 87,5% are independent ambulatory and capable of self-care
Heyland SF-36 and PQOL T Pt 16.6 ±10.6 months after hospital discharge
30 (77% ) · Survivors of sepsis had a significantly lower HRQL in the domains related
to physical and social function compared to the general U.S population HRQOL for survivors of sepsis were very similar to those for patients with chronic disease and survivors of acute lung injury.
T1 + 2 week 26 (87%)
Haraldsen Modified QOL scorea T/M Pt After ICU discharge 49 (46%) · Survivors of sepsis had impairments in QOL immediately after ICU- discharge compared to QOL before the time of admission for aspects of residence, social life, health, activity and subjective QOL.
· Most surviving patients regained good health and restitution of functional status · Subjectively appreciated QOL remained unchanged
6 years (2.0-14.8) after hospital discharge
49 (46%)
Granja EQ-5D PI Pt 6 months after ICU discharge 237 (61%; 104 sepsis, 133 controls)
· Sepsis survivors have a fair HRQOL at 6 months after ICU discharge , which is similar to that of non-sepsis ICU patients; except for anxiety/depression, in which sepsis survivors reported significantly fewer problems
Korosec EQ-5D T Pt or Pr(FM) 2 years after ICU treatment 39 (50%; sepsis 10, trauma 29)
· QOL was reduced equally in both the sepsis and trauma patients, 83% of patient reported a problem in at least one dimension of the EQ -5D . - Patients with sepsis had higher in-hospital and post-hospital mortality than trauma patients.
Hofhuis SF-36 PI or T Pr At ICU admission 170 (100%) · Severe sepsis survivors demonstrate a sharp multidimensional decline of HRQOL during ICU stay and a gradual improvement during the 6 months after ICU discharge
· Recovery at 6 months after ICU however, is incomplete in the physical functioning, role-physical and general health dimensions compared with preadmission status Pt At ICU discharge 121 (98%)
Pt At hospital discharge 101 (94%) Pt or Pr 3 mo after ICU discharge 96 (100%) Pt or Pr 6 months after ICU discharge 95(100%) Karlsson EQ-5D with EQsum
and EQ-VAS
M Pt or Pr(FM) 1 week after study entry 252 (53.6%) · Two year mortality after severe sepsis is high (44.9%)- Surviving sepsis patients have a lower QOL than the age- and sex-adjusted population
· Cost in QALY increases with age, mean QALY however is reasonable and intensive care in patients with severe sepsis is cost effective.
17 months after discharge (12-20) 156 (58%)
Poulsen SF-36 and self-composed questionnaire
T or M Pt 1 year (6-18 months) after septic shock
70 (88%) · Septic shock survivors have significantly reduced physical function 1 year after discharge
· The scores for domains related to physical health and both the PCS and MSC were all severely reduced in the septic shock patients compared with the age- and sex-matched control group from the general Danish population.
Lazosky SIP M Pt or Pr (FM) 1-4 years after surviving septic illness 23 (53% ; 8 sepsis, 15 cardiac)
· Sepsis survivors experience impairment in QOL, namely significant more problems during work than the control group due to problems with physical, sensory, emotional and cognitive functioning
Contrin EQ-5D and EQ-VAS T Pt or Pr (FM) > 1 year after ICU discharge 100 (34%; 50 sepsis, 50 controls)
· Older patients with sepsis had significantly higher prevalence of moderate and severe problems in all QOL dimensions of the EQ-5D - ICU survivors of sepsis have higher mortality rate than critically ill patients without sepsis
Cuthbertson SF-36 and EQ-5D T Pt 3.5 years after ICU admission 85 (46%) · Severe sepsis patients have a significantly lower physical QOL compared to the population norm 5 years after sepsis
· Mental QOL scores were only slightly below age- and sex matched population norms 5 years after severe sepsis
· 80% of patients were mostly or very happy with their current QOL despite their low QOL score at both 3.5 and 5 years
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
Table 3. Assessment of quality of life (QOL)
Author
QOL assessment
Follow up period (IQR); mean ± SD Response Rate, n (% of QOL responders) Key Findings for QoL
Instrument Method Who
McLauchlan WHO -PS M Pr (GP) 15 (3-39) months After hospital discharge
32 (78%) · QoL at 15 months after discharge for severe abdominal sepsis survivors is good, 87,5% are independent ambulatory and capable of self-care
Heyland SF-36 and PQOL T Pt 16.6 ±10.6 months after hospital discharge
30 (77% ) · Survivors of sepsis had a significantly lower HRQL in the domains related
to physical and social function compared to the general U.S population HRQOL for survivors of sepsis were very similar to those for patients with chronic disease and survivors of acute lung injury.
T1 + 2 week 26 (87%)
Haraldsen Modified QOL scorea T/M Pt After ICU discharge 49 (46%) · Survivors of sepsis had impairments in QOL immediately after ICU- discharge compared to QOL before the time of admission for aspects of residence, social life, health, activity and subjective QOL.
· Most surviving patients regained good health and restitution of functional status · Subjectively appreciated QOL remained unchanged
6 years (2.0-14.8) after hospital discharge
49 (46%)
Granja EQ-5D PI Pt 6 months after ICU discharge 237 (61%; 104 sepsis, 133 controls)
· Sepsis survivors have a fair HRQOL at 6 months after ICU discharge , which is similar to that of non-sepsis ICU patients; except for anxiety/depression, in which sepsis survivors reported significantly fewer problems
Korosec EQ-5D T Pt or Pr(FM) 2 years after ICU treatment 39 (50%; sepsis 10, trauma 29)
· QOL was reduced equally in both the sepsis and trauma patients, 83% of patient reported a problem in at least one dimension of the EQ -5D . - Patients with sepsis had higher in-hospital and post-hospital mortality than trauma patients.
Hofhuis SF-36 PI or T Pr At ICU admission 170 (100%) · Severe sepsis survivors demonstrate a sharp multidimensional decline of HRQOL during ICU stay and a gradual improvement during the 6 months after ICU discharge
· Recovery at 6 months after ICU however, is incomplete in the physical functioning, role-physical and general health dimensions compared with preadmission status Pt At ICU discharge 121 (98%)
Pt At hospital discharge 101 (94%) Pt or Pr 3 mo after ICU discharge 96 (100%) Pt or Pr 6 months after ICU discharge 95(100%) Karlsson EQ-5D with EQsum
and EQ-VAS
M Pt or Pr(FM) 1 week after study entry 252 (53.6%) · Two year mortality after severe sepsis is high (44.9%)- Surviving sepsis patients have a lower QOL than the age- and sex-adjusted population
· Cost in QALY increases with age, mean QALY however is reasonable and intensive care in patients with severe sepsis is cost effective.
17 months after discharge (12-20) 156 (58%)
Poulsen SF-36 and self-composed questionnaire
T or M Pt 1 year (6-18 months) after septic shock
70 (88%) · Septic shock survivors have significantly reduced physical function 1 year after discharge
· The scores for domains related to physical health and both the PCS and MSC were all severely reduced in the septic shock patients compared with the age- and sex-matched control group from the general Danish population.
Lazosky SIP M Pt or Pr (FM) 1-4 years after surviving septic illness 23 (53% ; 8 sepsis, 15 cardiac)
· Sepsis survivors experience impairment in QOL, namely significant more problems during work than the control group due to problems with physical, sensory, emotional and cognitive functioning
Contrin EQ-5D and EQ-VAS T Pt or Pr (FM) > 1 year after ICU discharge 100 (34%; 50 sepsis, 50 controls)
· Older patients with sepsis had significantly higher prevalence of moderate and severe problems in all QOL dimensions of the EQ-5D - ICU survivors of sepsis have higher mortality rate than critically ill patients without sepsis
Cuthbertson SF-36 and EQ-5D T Pt 3.5 years after ICU admission 85 (46%) · Severe sepsis patients have a significantly lower physical QOL compared to the population norm 5 years after sepsis
· Mental QOL scores were only slightly below age- and sex matched population norms 5 years after severe sepsis
· 80% of patients were mostly or very happy with their current QOL despite their low QOL score at both 3.5 and 5 years
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
Table 3. (continued)
Author
QOL assessment
Follow up period (IQR); mean ± SD Response Rate, n (% of QOL responders) Key Findings for QoL
Instrument Method Who
Nesseler SF-36 M or T Proxiesb 48 hour after the occurrence of sepsis 39 (U) · Sepsis survivors had a significant decrease in all 8 domains of the SF-36 , when compared to that of the general French population.
· HRQOL at baseline was impaired compared to general population. Although the physical component score improved at 6 months when compared to baseline (n=23), HRQOL remained lower than that in the general population.
Pt 6 months after episode of septic shock
48 (94%)
Orwelius Self-rated questionnaire including EQ-5D
M Pt 6 months after ICU discharge 313 (52%; 91 sepsis, 222 controls)
· Patients with community acquired sepsis (CAS) had more severity of illness, longer ICU stay and higher mortality during and after ICU stay but HRQOL was not significantly different from ICU survivors with other diagnoses
Rosendahl HADS , GSCL, PSS, SF-12
M Pt 55 months (2-117) after ICU discharge
144 (26%) · Compared with German normative samples, patients report greater anxiety, poorer mental and physical HRQOL and greater exhaustion
· Spouses have significant impaired mental HRQOL and increased anxiety · There is a significant dyadic association between patients and spouses regarding
mental health and physical health, namely anxiety, depression, mental HRQOL as well as gastrointestinal and musculoskeletal complaints, exhaustion and physical HRQOL
Zhang SF-36 PI Pt, Pr (GP) 38.43 months after hospital discharge 75 (51%; 42 sepsis, 33 controls)
· Survivors of sepsis have a similar HRQOL as other non-septic critically ill patients · Sepsis survivors had a significant decrease in 4 domains of the SF-36 when
compared to community controls: physical functioning, vitality role-emotional, mental health.
· HRQOL in survivors of severe sepsis was impaired up to 6 years after hospital discharge compared to the community control group
Gallop EQ-5D and HADS PI or T Pt or Pr (FM or F)
12 months after episode of severe sepsis
39 (U) · Survivors of severe sepsis and their caregivers experienced enduring loss of independence and emotional, work and financial impacts
ADL= Activies of Daily Living, E=E-mail, EQ-5D= EuroQol five dimensions questionnaire, EQ-sum= EuroQol-sum, EQ-VAS= EuroQol Visual Analog Scale, F=Friends, FM= Family member, GP= General practicioner, GSCL= Giessen Subjective Complaints List, HADS= Hospital Anxiety and Depression Scale, HRQOL= Health related quality of life, IADL= Instrumental Activities of Daily Living, ICU= Intensive care unit, IQCODE= Informant Questionnaire on Cognitive Decline in the Elderly, M=mail, M-TICS= Modified Telephone Interview for Cognitive Status, PI= Personal interview, PQOL= Perceived Quality of Life Scale, PSS= Posttraumatic Symptom Scale, Pr= Proxy, Pt= Patient, SF-12= Short Form-12 Health Survey, QOL= Quality of life, SIP= Sickness I
mpact Profile, SF-36= 36 Item Short Form Survey, T=Telephone, T1= first follow-up moment, U=Unknown, WHO-PS= WHO Performance Score
aHaraldsen: HRQOl after ICU discharge of all eligible patients who were admitted to the ICU during the period of January
1983 till December 1995. The modified QOL score of eligible patients in that period, was thus assessed after December 1995.
bHRQOL was assessed with respect to the 4- week period prior to hospital admission (baseline). SF 36 was completed within 48
h of the occurrence of sepsis through proxies.
to an age and/or gender-matched or the general population. Although recovery was
reported in two studies (23, 24), this was often incomplete and does not reach the same
level as preadmission status. In addition, this review shows HRQOL when compared to
the general population can remain impaired many years after hospital discharge (21, 31).
The wide ranges in follow-up periods and the different type of septic patients included in
the studies caused heterogeneity in HRQOL.
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
Table 3. (continued)
Author
QOL assessment
Follow up period (IQR); mean ± SD Response Rate, n (% of QOL responders) Key Findings for QoL
Instrument Method Who
Nesseler SF-36 M or T Proxiesb 48 hour after the occurrence of sepsis 39 (U) · Sepsis survivors had a significant decrease in all 8 domains of the SF-36 , when compared to that of the general French population.
· HRQOL at baseline was impaired compared to general population. Although the physical component score improved at 6 months when compared to baseline (n=23), HRQOL remained lower than that in the general population.
Pt 6 months after episode of septic shock
48 (94%)
Orwelius Self-rated questionnaire including EQ-5D
M Pt 6 months after ICU discharge 313 (52%; 91 sepsis, 222 controls)
· Patients with community acquired sepsis (CAS) had more severity of illness, longer ICU stay and higher mortality during and after ICU stay but HRQOL was not significantly different from ICU survivors with other diagnoses
Rosendahl HADS , GSCL, PSS, SF-12
M Pt 55 months (2-117) after ICU discharge
144 (26%) · Compared with German normative samples, patients report greater anxiety, poorer mental and physical HRQOL and greater exhaustion
· Spouses have significant impaired mental HRQOL and increased anxiety · There is a significant dyadic association between patients and spouses regarding
mental health and physical health, namely anxiety, depression, mental HRQOL as well as gastrointestinal and musculoskeletal complaints, exhaustion and physical HRQOL
Zhang SF-36 PI Pt, Pr (GP) 38.43 months after hospital discharge 75 (51%; 42 sepsis, 33 controls)
· Survivors of sepsis have a similar HRQOL as other non-septic critically ill patients · Sepsis survivors had a significant decrease in 4 domains of the SF-36 when
compared to community controls: physical functioning, vitality role-emotional, mental health.
· HRQOL in survivors of severe sepsis was impaired up to 6 years after hospital discharge compared to the community control group
Gallop EQ-5D and HADS PI or T Pt or Pr (FM or F)
12 months after episode of severe sepsis
39 (U) · Survivors of severe sepsis and their caregivers experienced enduring loss of independence and emotional, work and financial impacts
ADL= Activies of Daily Living, E=E-mail, EQ-5D= EuroQol five dimensions questionnaire, EQ-sum= EuroQol-sum, EQ-VAS= EuroQol Visual Analog Scale, F=Friends, FM= Family member, GP= General practicioner, GSCL= Giessen Subjective Complaints List, HADS= Hospital Anxiety and Depression Scale, HRQOL= Health related quality of life, IADL= Instrumental Activities of Daily Living, ICU= Intensive care unit, IQCODE= Informant Questionnaire on Cognitive Decline in the Elderly, M=mail, M-TICS= Modified Telephone Interview for Cognitive Status, PI= Personal interview, PQOL= Perceived Quality of Life Scale, PSS= Posttraumatic Symptom Scale, Pr= Proxy, Pt= Patient, SF-12= Short Form-12 Health Survey, QOL= Quality of life, SIP= Sickness I
mpact Profile, SF-36= 36 Item Short Form Survey, T=Telephone, T1= first follow-up moment, U=Unknown, WHO-PS= WHO Performance Score
aHaraldsen: HRQOl after ICU discharge of all eligible patients who were admitted to the ICU during the period of January
1983 till December 1995. The modified QOL score of eligible patients in that period, was thus assessed after December 1995.
bHRQOL was assessed with respect to the 4- week period prior to hospital admission (baseline). SF 36 was completed within 48
h of the occurrence of sepsis through proxies.
HRQOL, such as a cognitive decline and physical limitations can persist long after a sepsis
episode and significant influences daily life after hospitalization. A sepsis episode may
be a stressful traumatic experience, and apart from having severe negative effects on
the HRQOL it might also influence the HRQOL of their caregivers (22, 32). The HRQOL of
caregivers can also worsen in areas of mental health, physical health and may even have
financial impacts due to a shift in responsibilities within the family.
The included studies in this review show that an episode of sepsis has significant
impact on survivors which continues long after medical treatment has ceased. Therefore
the following aspects and interventions which could potentially limit this decrease in
HRQOL might be beneficial.
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
admission. In the past, patients with other critical, time-dependent illnesses such as acute
coronary syndrome, multiple trauma and stroke (34) have also profited from such clinical
pathways. These pathways should a have a multidisciplinary approach, aimed at bringing
different health care providers together and focus on the treatment of the acutely ill
septic patient, as well as prevention and reduction of possible long-term complications.
Previous studies investigating the use of certain intervention programmes in the ICU for
mechanically ventilated patients (35-37), showed that implementation led to a shorter
duration of delirium and more importantly an improvement in functional and physical
outcomes. In addition, Jones et al. showed that the use of intervention programmes lead
to a reduction of the risk of depression after ICU discharge (37).
Post hospital rehabilitation programmes can also be beneficial for sepsis survivors in
improving cognitive performance and functional outcomes (38). Although these studies
did not specifically compare groups of septic patients, these results might be translatable
to septic patients in the ICU. Specific rehabilitation programs targeting physical and
cognitive rehabilitation should start early, preferably from the time of admission and
continue till acceptable recovery. Creating clinical pathways to optimize sepsis care might
not only limit the decrease of HRQOL (35-38) but might also decrease the length of stay
in the ICU and hospital. Despite the cost associated with these intervention programs,
implementation may lead to long-term financial benefits (39). Moreover, it might decrease
Table 4. Study quality criteria (adapted from the U.S. Preventive Task Force)
Author No major exclusion criteria* Assesment of quality of life (QOL) at baseline Description of losses to follow up Adjusted for age and/or gender
McLauchlan √ - - -Heyland √ - √a √ Haraldsen √ - √ -Granja - √ - √ Korosec √ - √ -Hofhuis Ub √ √ √ Karlsson √ √ √ √ Poulsen √ - √ √ Lazosky Uc - √ √ Contrin √ - √ √ Cuthbertson √ - - √ Nesseler √ √ - √ Orwelius Ub √ √ Rosendahl √ - √ √ Zhang - - √ √ Gallop Uc √ -
-* Defined as systematic exclusion of >10% of the adult ICU population with a length of stay >24 h; U= Unknown
a Losses to follow-up are only described at the first follow-up moment. b Patients which had sepsis, but stayed for
a time period shorter than 48 hours in the ICU were not included. However, the article does not describe how many patients fulfilled these criteria and whether there were any major exclusion criteria; cMultiple exclusion criteria are
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
This decrease in readmission rate might also benefit the Acute Medical Unit (AMU),
which functions as a gateway between the ED and AMU. To the best of our knowledge
no studies have been conducted on the relation between specifically sepsis related
readmissions and strain on the AMU. Future work on this subject is therefore warranted.
Furthermore, it is important to identify risk factors associated with low HRQOL
in order to raise the standard of care and improve HRQOL for these patients. One of
these risk factors is age, as sepsis usually occurs in the elderly population. A thorough
assessment of elderly patients prior to discharge should take place to evaluate their need
for intermediate care and further recovery (41). Inclusion of family members and other
informal caregivers must not be forgotten in the treatment and rehabilitation.
Our study has many strengths. First, the studies included for this review contain
patients from different continents. This large diversity in the population group means
that the findings are probably not limited to one country or one continent. Secondly,
the studies in our review included patients with varying severity of sepsis and patients of
both the medical and surgical unit of intensive cares. Thirdly, the included studies span
from a period of 1996 until 2016 with both short and long follow-up time. Moreover,
almost all studies used validated HRQOL instruments such as the SF-36 and EQ-5D to
assess the quality of life, the use of specific non validated instruments was limited.
However, while interpreting the results of the included studies some limitations should
be taken into account. We could not perform a meta-analysis due to the heterogeneity in
the methodology and the study populations. The different types of methods in assessing
HRQOL may also influence the results.
Some studies in our review assessed the HRQOL questionnaires via telephone,
which might give a distorted view of the reality, since literature has shown that patients
are more likely to rate their health more favourable in phone interviews and face to
face assessments, compared to self-administered questionnaires (42, 43). A possible
explanation for this might be the perceived anonymity that patients who fill in
self-administered questionnaires experience (43). Another important consideration, is that
patients with the worst HRQOL are often those who do not participate in follow-up
assessments (12). This might cause an underestimation of the actual effect of sepsis in
decreasing the HRQOL in sepsis survivors.
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
Another important aspect is that patients who suffer from sepsis differ from
the general population, not only in age and gender but also in their comorbidities and
diagnostic category (47). Some studies compared HRQOL of sepsis survivors with that of
a general population, however the baseline health status of patients who survive the ICU
and an episode of sepsis may not be the same (46). Except for age- and/or gender none
of the studies specifically adjusted for other potential confounders.
It is important for both health care providers and patients to understand the impact
a sepsis episode can have on the HRQOL of survivors and their caregivers. Sepsis and
related ICU admission should not be considered a temporary physical burden, but as
a serious illness which has a significant impact on the HRQOL. Apart from focusing
on improving short-term outcomes, more attention is needed to prevent and reduce
long-term complications, which might negatively influence the HRQOL.
CONCLUSION
This review aimed to give an comprehensive overview of the literature available on HRQOL
of sepsis survivors after ICU admission. Survivors of sepsis show (significantly) impaired
quality of life in both physical and mental domains. These impairments may last several
years after hospital discharge. Upcoming trials should look beyond improving short
term mortality but also on improving HRQOL and thereby reintegrating patients back
into society.
ACKNOWLEDGEMENTS
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
REFERENCES
1. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001;29(7):1303-1310. 2. Desai SV, Law TJ, Needham DM. Long-term complications of critical care. Crit Care Med 2011;39(2):371-379. 3. Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med 2013;369(9):840-851. 4. Kaukonen KM, Bailey M, Suzuki S, et al. Mortality related to severe sepsis and septic shock among
critically ill patients in Australia and New Zealand, 2000-2012. JAMA 2014;311(13):1308-1316. 5. Brun-Buisson C, Meshaka P, Pinton P, et al. EPISEPSIS: a reappraisal of the epidemiology and outcome
of severe sepsis in French intensive care units. Intensive Care Med 2004;30(4):580-588.
6. Fletcher SN, Kennedy DD, Ghosh IR, et al. Persistent neuromuscular and neurophysiologic abnormalities in long-term survivors of prolonged critical illness. Crit Care Med 2003;31(4):1012-1016.
7. Hofhuis JG, Spronk PE, van Stel HF, et al. The impact of critical illness on perceived health-related quality of life during ICU treatment, hospital stay, and after hospital discharge: a long-term follow-up study. Chest 2008;133(2):377-385.
8. Cuthbertson BH, Scott J, Strachan M, et al. Quality of life before and after intensive care. Anaesthesia 2005;60(4):332-339.
9. Dowdy DW, Eid MP, Sedrakyan A, et al. Quality of life in adult survivors of critical illness: a systematic review of the literature. Intensive Care Med 2005;31(5):611-620.
10. Sacanella E, Perez-Castejon JM, Nicolas JM, et al. Functional status and quality of life 12 months after discharge from a medical ICU in healthy elderly patients: a prospective observational study. Crit Care 2011;15(2):R105.
11. Oeyen SG, Vandijck DM, Benoit DD, et al. Quality of life after intensive care: a systematic review of the literature. Crit Care Med 2010;38(12):2386-2400.
12. Winters BD, Eberlein M, Leung J, et al. Long-term mortality and quality of life in sepsis: a systematic review. Crit Care Med 2010;38(5):1276-1283.
13. Tromp M, Tjan DH, van Zanten AR, et al. The effects of implementation of the Surviving Sepsis Campaign in the Netherlands. Neth J Med 2011;69(6):292-298.
14. Castellanos-Ortega A, Suberviola B, Garcia-Astudillo LA, et al. Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: results of a three-year follow-up quasi-experimental study. Crit Care Med 2010;38(4):1036-1043.
15. Harris RP, Helfand M, Woolf SH, et al. Current methods of the US Preventive Services Task Force: a review of the process. Am J Prev Med 2001;20(3 Suppl):21-35.
16. Sawaya GF, Guirguis-Blake J, LeFevre M, et al. Update on the methods of the U.S. Preventive Services Task Force: estimating certainty and magnitude of net benefit. Ann Intern Med 2007;147(12):871-875. 17. Hofhuis JG, Spronk PE, van Stel HF, et al. The impact of severe sepsis on health-related quality of life:
a long-term follow-up study. Anesth Analg 2008;107(6):1957-1964.
18. Karlsson S, Ruokonen E, Varpula T, et al. Long-term outcome and quality-adjusted life years after severe sepsis. Crit Care Med 2009;37(4):1268-1274.
19. Poulsen JB, Moller K, Kehlet H, et al. Long-term physical outcome in patients with septic shock. Acta Anaesthesiol Scand 2009;53(6):724-730.
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
21. Nesseler N, Defontaine A, Launey Y, et al. Long-term mortality and quality of life after septic shock: a follow-up observational study. Intensive Care Med 2013;39(5):881-888.
22. Rosendahl J, Brunkhorst FM, Jaenichen D, et al. Physical and mental health in patients and spouses after intensive care of severe sepsis: a dyadic perspective on long-term sequelae testing the Actor-Partner Interdependence Model. Crit Care Med 2013;41(1):69-75.
23. McLauchlan GJ, Anderson ID, Grant IS, et al. Outcome of patients with abdominal sepsis treated in an intensive care unit. Br J Surg 1995;82(4):524-529.
24. Haraldsen P, Andersson R. Quality of life, morbidity, and mortality after surgical intensive care: a follow-up study of patients treated for abdominal sepsis in the surgical intensive care unit. Eur J Surg Suppl 2003(588):23-27.
25. Korosec JH, Jagodic K, Podbregar M. Long-term outcome and quality of life of patients treated in surgical intensive care: a comparison between sepsis and trauma. Crit Care 2006;10(5):R134. 26. Granja C, Dias C, Costa-Pereira A, et al. Quality of life of survivors from severe sepsis and septic shock
may be similar to that of others who survive critical illness. Crit Care 2004;8(2):R91-R98.
27. Orwelius L, Fredrikson M, Kristenson M, et al. Health-related quality of life scores after intensive care are almost equal to those of the normal population: A multicenter observational study. Critical Care 2013;17(5). 28. Heyland DK, Hopman W, Coo H, et al. Long-term health-related quality of life in survivors
of sepsis. Short Form 36: a valid and reliable measure of health-related quality of life. Crit Care Med 2000;28(11):3599-3605.
29. Lazosky A, Young GB, Zirul S, et al. Quality of life after septic illness. J Crit Care 2010;25(3):406-412. 30. Contrin LM, Paschoal VD, Beccaria LM, et al. Quality of life of severe sepsis survivors after hospital
discharge. Rev Lat Am Enfermagem 2013;21(3):795-802.
31. Zhang K, Mao X, Fang Q, et al. Impaired long-term quality of life in survivors of severe sepsis : Chinese multicenter study over 6 years. Anaesthesist 2013;62(12):995-1002.
32. Gallop KH, Kerr CE, Nixon A, et al. A qualitative investigation of patients’ and caregivers’ experiences of severe sepsis*. Crit Care Med 2015;43(2):296-307.
33. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003;31(4):1250-1256.
34. Ghosh R, Pepe P. The critical care cascade: a systems approach. Curr Opin Crit Care 2009;15(4):279-283. 35. Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with
acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010;91(4):536-542. 36. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically
ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373(9678):1874-1882. 37. Jones C, Skirrow P, Griffiths RD, et al. Rehabilitation after critical illness: a randomized, controlled
trial. Crit Care Med 2003;31(10):2456-2461.
38. Jackson JC, Ely EW, Morey MC, et al. Cognitive and physical rehabilitation of intensive care unit survivors: results of the RETURN randomized controlled pilot investigation. Crit Care Med 2012;40(4):1088-1097. 39. Lord RK, Mayhew CR, Korupolu R, et al. ICU early physical rehabilitation programs: financial modeling
of cost savings. Crit Care Med 2013;41(3):717-724.
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
42. Lyons RA, Wareham K, Lucas M, et al. SF-36 scores vary by method of administration: implications forstudy design. J Public Health Med 1999;21(1):41-45.
43. Perkins JJ, Sanson-Fisher RW. An examination of self- and telephone-administered modes of administration for the Australian SF-36. J Clin Epidemiol 1998;51(11):969-973.
44. Sprangers MA, Schwartz CE. Integrating response shift into health-related quality of life research: a theoretical model. Soc Sci Med 1999;48(11):1507-1515.
45. Albrecht GL, Devlieger PJ. The disability paradox: high quality of life against all odds. Soc Sci Med 1999;48(8):977-988.
46. Gifford JM, Husain N, Dinglas VD, et al. Baseline quality of life before intensive care: a comparison of patient versus proxy responses. Crit Care Med 2010;38(3):855-860.
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
APPENDIX
APPENDIX 1: SEARCH STRATEGY
PubMed (PM)
#1 {sepsis}
“Systemic Inflammatory Response Syndrome”[Mesh] OR SIRS[tiab] OR sepsis[tiab] OR
septic[tiab] OR urosepsis[tiab] OR Pyemia[tiab] OR Pyohemia[tiab] OR Pyaemia[tiab] OR
Pyemias[tiab] OR Septicemia[tiab] OR Septicemias[tiab] OR “Blood Poisoning”[tiab] OR
“Blood Poisonings”[tiab] OR Bacteremi*[tiab] OR bacteraemi*[tiab] OR Endotoxemia[tiab]
OR Septicemi*[tiab] OR septicaemi*[tiab] OR fungaemia[tiab] OR fungemia[tiab]
#2 {QoL}
“Quality of Life”[Mesh] OR “Quality-Adjusted Life Years”[Mesh] OR life qualit*[tiab] OR
“quality of life”[tiab] OR “Activities of Daily Living”[Mesh] OR “activities of daily living”[tiab]
OR daily living activit*[tiab] OR ADL[tiab] OR “chronic limitation of activity”[tiab] OR self
care[tiab] OR “Health Status”[Mesh] OR “Health Status Indicators”[Mesh:noexp] OR “level
of health”[tiab] OR health level*[tiab] OR QL[tiab] OR QoL[tiab] OR “HRQL”[tiab] OR
“HRQoL”[tiab] OR PQLS[tiab] OR QALY[tiab] OR “quality adjusted life years”[tiab] OR “short
form”[tiab] OR “SF 36”[tiab] OR NHP[tiab] OR “Nottingham Health Profile”[tiab] OR patient
reported outcome*[tiab] OR PROM[tiab] OR PROMIS[tiab] OR HR-PRO[tiab] OR HRPRO[tiab]
OR health index*[tiab] OR health indices[tiab] OR health profile*[tiab] OR health status[tiab]
#3 {volwassenen}
((“Adolescent”[Mesh] OR “Child”[Mesh] OR “Infant”[Mesh] OR adolescen*[tiab]
OR child*[tiab] OR schoolchild*[tiab] OR infant*[tiab] OR girl*[tiab] OR boy*[tiab] OR
teen[tiab] OR teens[tiab] OR teenager*[tiab] OR youth*[tiab] OR pediatr*[tiab] OR
paediatr*[tiab] OR puber*[tiab]) NOT (“Adult”[Mesh] OR adult*[tiab] OR man[tiab] OR
men[tiab] OR woman[tiab] OR women[tiab]))
#4 {mensen}
(animals[mh] NOT humans[mh])
#5 {publicatiefilter}
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
8
#1 AND #2 (NOT #4 NOT #5 NOT #6)
Search Query Items found
#6 Search #5 NOT (“addresses”[Publication Type] OR
“biography”[Publication Type] OR “case reports”[Publication Type] OR “comment”[Publication Type] OR “directory”[Publication Type] OR “editorial”[Publication Type] OR “festschrift”[Publication Type] OR “interview”[Publication Type] OR “lectures”[Publication Type] OR “legal cases”[Publication Type] OR “legislation”[Publication Type] OR “letter”[Publication Type] OR “news”[Publication Type] OR “newspaper article”[Publication Type] OR “patient education handout”[Publication Type] OR “popular works”[Publication Type] OR “congresses”[Publication Type] OR “consensus development conference”[Publication Type] OR “consensus development conference, nih”[Publication Type])
1543
#5 Search #4 NOT (animals[mh] NOT humans[mh]) 1676 #4 Search #3 NOT ((“Adolescent”[Mesh] OR “Child”[Mesh] OR
“Infant”[Mesh] OR adolescen*[tiab] OR child*[tiab] OR
schoolchild*[tiab] OR infant*[tiab] OR girl*[tiab] OR boy*[tiab] OR teen[tiab] OR teens[tiab] OR teenager*[tiab] OR youth*[tiab] OR pediatr*[tiab] OR paediatr*[tiab] OR puber*[tiab]) NOT (“Adult”[Mesh] OR adult*[tiab] OR man[tiab] OR men[tiab] OR woman[tiab] OR women[tiab]))
1787
#3 Search #1 AND #2 2092
#2 Search “Quality of Life”[Mesh] OR “Quality-Adjusted Life Years”[Mesh]
OR life qualit*[tiab] OR “quality of life”[tiab] OR “Activities of Daily Living”[Mesh] OR “activities of daily living”[tiab] OR daily living activit*[tiab] OR ADL[tiab] OR “chronic limitation of activity”[tiab] OR self care[tiab] OR “Health Status”[Mesh] OR “Health Status Indicators”[Mesh:noexp] OR “level of health”[tiab] OR health level*[tiab] OR QL[tiab] OR QoL[tiab] OR “HRQL”[tiab] OR “HRQoL”[tiab] OR PQLS[tiab] OR QALY[tiab] OR “quality adjusted life years”[tiab] OR “short form”[tiab] OR “SF 36”[tiab] OR NHP[tiab] OR “Nottingham Health Profile”[tiab] OR patient reported outcome*[tiab] OR PROM[tiab] OR PROMIS[tiab] OR HR-PRO[tiab] OR HRPRO[tiab] OR health index*[tiab] OR health indices[tiab] OR health profile*[tiab] OR health status[tiab]
458519
#1 Search “Systemic Inflammatory Response Syndrome”[Mesh] OR
SIRS[tiab] OR sepsis[tiab] OR septic[tiab] OR urosepsis[tiab] OR Pyemia[tiab] OR Pyohemia[tiab] OR Pyaemia[tiab] OR Pyemias[tiab] OR Septicemia[tiab] OR Septicemias[tiab] OR “Blood Poisoning”[tiab] OR “Blood Poisonings”[tiab] OR Bacteremi*[tiab] OR bacteraemi*[tiab] OR Endotoxemia[tiab] OR Septicemi*[tiab] OR septicaemi*[tiab] OR fungaemia[tiab] OR fungemia[tiab]
192316
EMBASE (EMB)
#1 {sepsis}
LONG-TERM HEAL
TH RELA
TED QUALITY OF LIFE IN P
A
TIENTS WITH SEPSIS
