A326 THE IMPACT OF DELAYED SOURCE CONTROL AND ANTIMICROBIAL THERAPY IN 196 PATIENTS WITH CHOLECYSTITIS-ASSOCIATED SEPTIC SHOCK. (1st March 2018)

• Record Type: Journal Article
• Authors: Dong, V; Karvellas, C J; Abraldes, J; Lester, E; Kumar, A
• Is Part Of: Journal of the Canadian Association of Gastroenterology. Volume 1(2018)Supplement 2
• Page Start: 468
• Page End: 469
• Publication Date: 2018-03-01
• Subjects: Gastroenterology -- Periodicals; 616.33005
• DOI: 10.1093/jcag/gwy009.326
• Languages: English
• ISSNs: 2515-2084

Abstract

Abstract: Background: Cholecystitis-associated septic shock carries significant mortality. Treatment includes early administration of antibiotics along with source control (cholecystectomy or percutaneous cholecystostomy drainage). There is uncertainty regarding most appropriate time to achieve source control. Aims: Our aim is to determine whether timing of source control affects survival in cholecystitis patients with septic shock. Methods: Nested retrospective cohort study of all cholecystitis-associated septic shock patients (met Tokyo guidelines for cholecystitis along with hypotension requiring vasopressors) from an international, multicenter database from 1996 to 2015. Multivariate logistic regression analysis was performed to assess association between practice related factors (delay to source control and antibiotics) and severity of illness on hospital mortality. Classification and regression tree (CART) analysis was used to evaluate the interaction between non-linear covariates. Results: Among 196 patients (mean age 69 years, 70% male), overall mortality was 37%. Compared to non-survivors (n=72), survivors (n=124) had lower mean admission Acute Physiology and Chronic Health Evaluation (APACHE) II scores (21 vs. 27, p<0.001) and lower median admission serum lactate (2.4 vs. 6.8 µmol/L, p<0.001). Survivors were more likely to receive appropriate antimicrobial therapy earlier (median 2.8 vs. 6.1 hours from shock, p=0.012). Survivors were also more likely to undergo successful source control earlier (median 9.8 vs. 24.7 hours, p<0.001). Adjusting for covariates, APACHEII [Odds ratio (OR) 1.13 (95% CI 1.06–1.21) per increment] and delayed source control >16 hours [OR 4.45 (1.88–10.70)] were independently associated with increased mortality (p<0.001 for all; c-statistic 0.800). CART analysis showed time to source control could only split the node containing patients with APACHEII of 15 to 26 but did not add classification value to patients with lower or higher APACHEII scores (see Figure 1). Patients with APACHEII <15 had a 94% survival rate and those with APACHEII >16 had a 33% survival rate. CART analysis demonstrated patients with APACHEII of 15 to 26 benefitted most from source control within 16 hours (92% vs. 48% survival) (p<0.0001, see Figure 1). Conclusions: Patients with cholecystitis-associated septic shock have significant mortality. Admission APACHEII score and delay in source control >16 hours significantly affected hospital outcomes. This suggests urgent source control (within 16 hours) could improve outcomes in high-risk patients. Funding Agencies: None