Sepsis is a serious problem for patients in the Intensive Care Unit (ICU). Sepsis can lead to septic shock, in turn multi-organ system failure, and can ultimately lead to death. The statistics on the mortality rate of sepsis are staggering. The mortality rate in the United States for patients admitted to the ICU with sepsis is around 11%, and is considered to be one of the most common causes of death in ICU patients (Joannidis, 2009). Sepsis can turn into septic shock very quickly, are most often occurs within the first twenty-four hours of admission to the hospital (Rivers, McIntyre, Morro, & Rivers, 2005).
Oxygen delivery and utilization due to the bodies response to infection, is impaired causing global tissue hypoxia (Otero, Nguyen, Huang, Gaieski, Goyal, Gunnerson,… Rivers, 2006). Tissue hypoxia is due to the inflammatory response the body has during infection, and can in turn even stimulate more inflammation. The microcirculation in the body is also altered during sepsis and septic shock, and can lead to metabolic and respiratory acidosis. Although all organs can be affected by sepsis and septic shock, one of the most common organs affected are the kidneys.
Acute kidney injury (AKI) when accompanied by sepsis not only increases patient morbidity, it increases mortality. In the ICU it is noted that as high as approximately “50% of new-onset AKI” (Oh, Kim, Ahn, Ku, Park, Han,… Kim, 2016) cases are caused by sepsis. When AKI is combined with septic shock the mortality rate can be as high as 75% (Joannidis, 2009). The goal of therapy in the ICU is to treat patients as effectively as possible, and achieve the best possible outcome. The problem is that currently patients with septic AKI are not being treated with early goal directed therapy (EGDT) including continuous renal replacement therapy (CRRT), and they are in turn having poor outcomes. The question becomes, does EGDT with CRRT improve patient survival in the setting of sepsis/septic shock in the ICU? In order to find an answer, quantitative studies, and RCT trials have to continue. Preferably real time RTC during patient’s hospitalizations are most beneficial, but retrospective analysis of past patients can be utilized as well. Trials and studies that have already been completed have been analyzed below.
All of the studies reviewed were quantitative in nature, performed to show the correlation of EGDT with CRRT and improved mortality. Each study conducted had the inclusion criteria of patients having both AKI and sepsis or septic shock. All studies were retrospective in nature and included extensive chart review. The main difference in the studies included the criteria for what was considered “early or late” initiation of CRRT. When to start CRRT, and what is considered early or late initiation, has not at this time been standardized. Determining when to start CRRT differs from study to study. Only one study measured early and late initiation in hours from the start time with early initiation being less than 26.4 hours between the time of EGDT enrollment and commencement of CRRT, and late being greater than 26.4 hours (Oh et al., 2016).
The research clearly shows that EGDT with CRRT therapy can improve patient outcomes in the ICU setting. Although mortality rate is still high in patients with sepsis or septic shock requiring CRRT therapy, early CRRT initiation was associated with significantly higher survival rate compared to late initiation “pooled OR 0.45; 95% CI, 0.28 to 0.72, P < 0.001″ (Karvellas et al., 2011). Even after adjusting for high mortality risk patients with comorbidities such as diabetes, liver failure, and APACHE II scores the 28-day mortality risk was much higher in the late initiation group “HR, 2.461; 95% CI, 1.044- 5.800; P= 0.026” (Oh et al., 2016). The same study had 28-day mortality percentages as “56.7% vs 30%, P= 0.037” in the late vs early initiation groups. Not only has it been shown that the 28-day mortality risk is improved with EGDT with CRRT in sepsis patients, but studies have also shown important secondary outcome improvements as well.
Vasopressor use was shown to be significantly reduced in CRRT patients twenty-four hours post treatment initiation early CRRT group “8.6 ± 3.5μg/min before CRRT start vs 7.2 ± 3.9μg/min after 24 hours from CRRT initiation, P= 0.39; late group CRRT: 7.8 ± 3.2μg/min before CRRT start vs 6.7 ± 3.9 μg/min after 24 hours from CRRT initiation, P=0.047” (Oh et al., 2016). Although both groups had reduction in vasopressor use, it was found that the early initiation group had a more significant degree of decline before and after CRRT initiation than the late group “1.4 ± 2.6 μg/min in early CRRT group vs 0.8 ± 3.1 μg/min in the late group, P=0.44” (Oh et al., 2016). Moreover, higher rates of kidney recovery, and shorter duration of CRRT in those receiving early CRRT initiation, along with a reduced length of stay in the ICU were also found (Karvellas et al., 2011).
Previous studies have noted that CRRT therapy is normally started six to eight days after ICU admission which is “considerably later that the 1.4 days reported by a recent worldwide practice survey” (Joannidis, 2009). It has been difficult to obtain data regarding CRRT on sepsis patients due to the fact that a large number or patients/families make the decision to withhold or withdraw care with the knowledge that the sepsis with AKI disease process has such a high mortality rate (Nagata, Uchino, Tokuhira, Ohnuma, Namba, Katayama, . . . Uji, 2015). The significance of this problem is clear to see from the material above.
The mortality rate in septic patients with AKI in the ICU is incredibly high. It has been shown that we can decrease this mortality rate, and improve secondary outcomes by using EGDT with CRRT initiation. Early initiation of CRRT in septic patients can not only improve mortality rate, but can decrease vasopressor use, improve kidney recovery chances, shorten the length of time CRRT is needed, and reduce the length of stay in the ICU.
