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Enhancing Recovery From SepsisA Review

Educational Objective
To review the clinical management of patients who survive sepsis.
1 Credit CME
Abstract

Importance  Survival from sepsis has improved in recent years, resulting in an increasing number of patients who have survived sepsis treatment. Current sepsis guidelines do not provide guidance on posthospital care or recovery.

Observations  Each year, more than 19 million individuals develop sepsis, defined as a life-threatening acute organ dysfunction secondary to infection. Approximately 14 million survive to hospital discharge and their prognosis varies. Half of patients recover, one-third die during the following year, and one-sixth have severe persistent impairments. Impairments include development of an average of 1 to 2 new functional limitations (eg, inability to bathe or dress independently), a 3-fold increase in prevalence of moderate to severe cognitive impairment (from 6.1% before hospitalization to 16.7% after hospitalization), and a high prevalence of mental health problems, including anxiety (32% of patients who survive), depression (29%), or posttraumatic stress disorder (44%). About 40% of patients are rehospitalized within 90 days of discharge, often for conditions that are potentially treatable in the outpatient setting, such as infection (11.9%) and exacerbation of heart failure (5.5%). Compared with patients hospitalized for other diagnoses, those who survive sepsis (11.9%) are at increased risk of recurrent infection than matched patients (8.0%) matched patients (P < .001), acute renal failure (3.3% vs 1.2%, P < .001), and new cardiovascular events (adjusted hazard ratio [HR] range, 1.1-1.4). Reasons for deterioration of health after sepsis are multifactorial and include accelerated progression of preexisting chronic conditions, residual organ damage, and impaired immune function. Characteristics associated with complications after hospital discharge for sepsis treatment are not fully understood but include both poorer presepsis health status, characteristics of the acute septic episode (eg, severity of infection, host response to infection), and quality of hospital treatment (eg, timeliness of initial sepsis care, avoidance of treatment-related harms). Although there is a paucity of clinical trial evidence to support specific postdischarge rehabilitation treatment, experts recommend referral to physical therapy to improve exercise capacity, strength, and independent completion of activities of daily living. This recommendation is supported by an observational study involving 30 000 sepsis survivors that found that referral to rehabilitation within 90 days was associated with lower risk of 10-year mortality compared with propensity-matched controls (adjusted HR, 0.94; 95% CI, 0.92-0.97, P < .001).

Conclusions and Relevance  In the months after hospital discharge for sepsis, management should focus on (1) identifying new physical, mental, and cognitive problems and referring for appropriate treatment, (2) reviewing and adjusting long-term medications, and (3) evaluating for treatable conditions that commonly result in hospitalization, such as infection, heart failure, renal failure, and aspiration. For patients with poor or declining health prior to sepsis who experience further deterioration after sepsis, it may be appropriate to focus on palliation of symptoms.

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Article Information

Corresponding Author: Hallie C. Prescott, MD, MSc, Department of Internal Medicine and Institute for Healthcare Policy & Innovation, University of Michigan, 2800 Plymouth Rd, North Campus Research Center, Bldg 16, 341E, Ann Arbor, MI 48109-2800 (hprescot@med.umich.edu).

Accepted for Publication: November 8, 2017.

Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Prescott reported receiving grant support from the National Institutes of Health and serving on the advisory board of a Bristol-Myers Squibb–sponsored study. Dr Angus reported that he has served as a consultant for Ferring Pharmaceuticals.

Funding/Support: This work was supported by grants K08 GM115859 (Dr Prescott) and R01 GM097471 (Dr Angus) from the National Institute of General Medical Sciences of the National Institutes of Health.

Disclaimer: The views expressed in this article do not necessarily reflect the position or policy of the US government or the Department of Veteran Affairs. Dr Angus, a JAMA associate editor, was not involved in the editorial evaluation of or decision to publish this article.

Additional Contributions: We thank Theodore “Jack” Iwashyna, MD, PhD, of the University of Michigan for thoughtful feedback on this review and Bronwen Connolly, MSc, PhD, MCSP, from St Thomas’ hospital in London for stimulating discussion on rehabilitation after sepsis. Neither were compensated for their contributions. We also thank the Michigan Center for Integrative Research in Critical Care.

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